CHAPTER 2 page 23
SUICIDE AND SPECIAL
PATIENT POPULATIONS
Of all medical conditions, cancer and acquired
immunodeficiency syndrome (AIDS) are associated with the highest
rates of suicide and suicide requests.(1) In general, the elderly
are also at increased risk of depression and suicide. Requests for
assisted suicide and euthanasia by these patients and others with
serious illnesses have fueled the debate about the physician's role
in responding to these requests.
The debate about legalizing assisted suicide and euthanasia
has also focused attention on the treatment available for patients
who are suffering from both physical and psychological pain.
Available data and research on suicidal ideation and suicide
attempts by patients with cancer and AIDS provide critical insight
about the relationship between terminal illness, the availability of
adequate palliative care, and suicide. The majority of AIDS and
cancer patients who express suicidal thoughts or commit suicide
suffer from unrecognized and untreated psychiatric conditions, such
as depression or confusional states, and poorly controlled pain.
Patients with other chronic and seriously disabling diseases,
such as degenerative neurological disorders, also experience
emotional and physical suffering. Chronic, nonterminal pain often
cannot be treated in the same manner as terminal pain. Some
severely debilitating illnesses cause suffering that differs from
the suffering experienced by AIDS and cancer patients.
Unfortunately, few data are available about suicide rates, pain, and
depression for patients with chronic illness.
---------------------------------------------------------------------------
(1) W. Breitbart, "Suicide Risk and Pain," in Current and
Emerging Issues in Cancer Pain: Research and Practice., ed.
C. R. Chapman and K. M. Foley (New York: Raven Press, 1993),
49-65.
page 24 WHEN DEATH IS SOUGHT
PATIENTS WITH CANCER
Cancer patients face approximately twice the risk of suicide
than the general population does, although few commit suicide. To
date, three major studies confirm the low incidence of suicide among
cancer patients. One study of cancer deaths in Finland, conducted
in 1979, found that only 63 out of 28,257 cancer patients who died
committed suicide.(2) In another study conducted in the United
States in 1982, researchers estimated that 192 of 144,530 cancer
deaths were the result of suicide. Finally, a 1985 Swedish study
reports that of 19,000 cancer deaths, only 22 were suicides.(3)
The risk of suicide is greatest for patients in the later
stages of the disease; 16 percent to 20 percent of these patients
experience suicidal ideation. In contrast, studies have found that
few ambulatory cancer patients express thoughts of suicide. Despite
the low rates of suicidal ideation reported by studies, health care
professionals who care for cancer patients believe that suicidal
thinking is prevalent among these patients.
Almost all patients who receive a cancer diagnosis, even when
the prognosis is good, carry a "secret," rarely acknowledged,
thought that says "I won't die in pain with advanced cancer - I'll
kill myself first." They often have a hidden supply of drugs which
is usually kept for this purpose. For most patients, the time never
comes to take the pills and life becomes dearer as death
approaches.(4)
Some psychiatrists urge that these feelings should be
acknowledged as an important and normal component of dealing with
cancer. These experts suggest that suicidal thinking is common
among patients as an option to enable them to retain a sense of
control or to avoid feeling overwhelmed by cancer.(5) Physicians
must be skilled at assessing when the thoughts are serious and
whether the patient suffers from major depression - especially for
those with a good prognosis or for whom the disease is in remission.
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(2) Suicide risk relative to the general population was 1.3 for
men and 1.9 for women. K. A. Louhivuori and M. Hakama, "Risk
of Suicide Among Cancer Patients", American Journal of
Epidemiology 109 (1979): 59-65.
(3) The U.S. study found the suicide risk relative to the
general population to be 2.3 for men; however, women were not
at increased risk (only 0.9). W. Breitbart, "Cancer Pain and
Suicide," in Advances in Pain Research and Therapy, ed. K. M.
Foley et al., vol. 16 (New York: Raven Press, 1990), 402.
(4) Jimmie C. Holland, Chief, Psychiatry Services, Memorial
Sloan-Kettering Cancer Center, "Letter to the Task Force on
Life and the Law," August 16, 1993.
(5) W. Breitbart, "Psychiatric Management of Cancer Pain,"
Cancer 63 (1989): 2336-42.
CHAPTER 2 - SUICIDE AND SPECIAL PATIENT POPULATIONS page 25
Several personal and medical factors increase the cancer
patient's vulnerability to suicide and suicidal ideation. Personal
factors that contribute to a wish for hastened death include a prior
history of suicide (personal or family), prior psychiatric disorder,
prior alcohol or drug abuse, depression and hopelessness, and recent
loss or bereavement. The medical risk factors are pain, delirium,
advanced illness, debilitation, and exhaustion or fatigue.(6)
Psychiatric disorders are frequently present in suicidal cancer
patients. A study at Memorial Sloan-Kettering Hospital in New York
City showed that one third of suicidal cancer patients suffered from
major depression, approximately 20 percent had delirium, and more
than 50 percent had an adjustment disorder.(7)
Loss of control and feelings of helplessness may be the most
significant factors for cancer patients who desire an early
death.(8)
Cancer or cancer treatments often cause symptoms that add to a
patient's feelings of helplessness. These symptoms may include loss
of mobility, paraplegia, loss of bowel and bladder function,
amputation, sensory loss, and an inability to eat or swallow. Most
distressing to many cancer patients is the sense that they are
losing control of their mental functions, especially when confused
or sedated by medications.
Cancer patients with delirium, even mild delirium, are at
increased risk of suicide. Confusional states contribute to
impulsive suicide attempts because the patient experiences a loss of
impulse control when delirious. Patients in a state of delirium may
therefore be more likely to act on a suicidal thought. In addition,
the delirium may add to the patient's sense of helplessness and
increase the likelihood of a suicide attempt.
Fatigue and exhaustion also contribute to a higher risk of
suicide. Cancer patients become not only physically exhausted by
the illness and treatments but also emotionally fatigued. Because
of the chronic nature of the illness and the drawn-out disease
process, the patient's or family's financial resources may also be
diminished. Otherwise committed and supportive family members and
health care professionals may also tire and abandon the patient.
--------------------------------------------------------------------------
(6) Holland, "Letter to Task Force"; Breitbart, "Psychiatric
Management of Cancer Pain."
(7) W. Breitbart, "Suicide in Cancer Patients," Oncology 1 (1987):49-53.
(8) W. Breitbart, "Cancer Pain and Suicide," 399-412.
Page 26 WHEN DEATH IS SOUGHT
Studies suggest that 20 percent to 25 percent of cancer
patients suffer major depression at some point during their illness.
Among patients with advanced cancer and progressively impaired
physical function, the presence of severe depressive symptoms rises
to 77 percent.(9) While these rates of depression may be high
relative to the general population, they are similar to those found
among patients suffering other physical illness.(10)
For cancer patients, pain, depression, and psychiatric
disorders are closely linked. Uncontrolled or poorly controlled
pain can increase a patient's feelings of hopelessness and
helplessness. One study of cancer patients showed that 47 percent
of patients had a psychiatric disorder (of whom 68 percent had
reactive anxiety or depression). The incidence of psychiatric
disorders - in particular anxiety and depression - was higher in
patients with pain.(11)
Treating cancer patients for depression and pain reduces
levels of suicidal ideation. Allowing patients to discuss suicidal
thoughts may also decrease the risk of suicide. A discussion can
help patients feel a sense of control over their death. Treatment
for depression can also eliminate a patient's wish to die. One
study of cancer patients at a major hospital found that nine percent
of psychiatric consultations concerned acutely suicidal patients.
Virtually all these patients had a previously undiagnosed
psychiatric disorder. Treatment for depression resulted in the
cessation of suicidal ideation for 90 percent of these patients.
Like the common myth that it is reasonable for terminally ill
patients to be suicidal, these data argue against the common
misperception that cancer patients appropriately suffer from severe
clinical depression.
Depression may be difficult to diagnose in cancer patients
because the standard criteria for diagnosing depression do not
consider special symptoms of cancer patients. For example, severe
pain may mask feelings of sadness. Somatic signs such as
disturbance of sleep or appetite may be produced by medications or
the illness. Physicians must be sensitive to the special risk
factors for depressive symptoms in cancer patients, especially the
medications that can cause such symptoms.
--------------------------------------------------------------------
(9) Ibid.
(10) Depression Guideline Panel, Depression in Primary Care:
vol. 1, Detection and Diagnosis, Clinical Practice Guideline,
no. 5, AHCPR pub. no. 93-0550 (Rockville, Md.: U. S.
Department of Health and Human Services, Public Health Service,
Agency for Health Care Policy and Research, April 1993), 63-64.
(11) W. Breitbart and J. C. Holland, "Psychiatric Aspects of
Cancer Pain," Advances in Pain Research and Therapy, ed. K. M.
Foley et al. vol. 16 (New York: Raven Press, 1990), 73-87.
CHAPTER 2 - SUICIDE AND SPEICAL PATIENT POPULATIONS page 27
While the experience of each patient is unique, certain types
of pain and suffering are commonly associated with particular
diseases. Studies show that 15 percent of patients with
nonmetastatic cancer have significant pain, and 60 percent to 90
percent of patients with advanced cancer have moderate to severe
pain, which impairs their functioning or mood.(12) Pain may arise
from multiple causes. Tumor growth can lead to tissue damage, and
can affect the nervous system, causing neuropathic pain. Treatments
for cancer, especially radiation and chemotherapy, can carry
significant side effects, including severe nausea and fatigue, loss
of appetite, disfigurement, loss of libido, and infertility. Pain
and other distressing symptoms are also caused by the disease
itself.(13)
The variety of symptoms experienced by advanced cancer
patients is illustrated by a study of 90 patients treated by a
supportive care program during the last four weeks of life. The
patients as a group reported 44 symptoms distressing enough to
interfere with activity. The most prevalent symptoms (spontaneously
identified by at least 10 percent of patients) were fatigue, pain,
weakness, sleepiness, confusion, anxiety, weakness of legs,
shortness of breath, and nausea. Other symptoms reported by at
least five percent of patients included decreased hearing, inability
to sleep, constipation, difficulty swallowing, and difficulty
speaking. Many patients reported multiple symptoms, most commonly
listing between two and four, but in one case as many as nine. The
simultaneous presence of multiple distressing symptoms adds to the
patient's suffering and poses special challenges for pain and
symptom management.(14 )
-------------------------------------------------------------------------------------
(12) K. M. Foley, "The Treatment of Cancer Pain," New England
Journal of Medicine 313 (1985): 84-85; W. Breitbart, "Suicide
Risk and Pain in Cancer and AIDS Patient," in Current and
Emerging Issues in Cancer Pain: Research and Practice, ed. C.
R. Chapman and K. M. Foley (New York: Raven Press, 1993),
49-65; N. Coyle et al. "Character of Terminal Illness in the
Advanced Cancer Patient: Pain and Other Symptoms During the
Last Four Weeks of Life," Journal of Pain and Symptom
Management 5 (1990):83.
(13) Foley, "Treatment of Cancer Pain," 85-86; R. K. Portenoy,
"Pain Assessment in Adults and Children," in Why Do We Care?
Syllabus of the Postgraduate Course, Memorial Sloan-Kettering
Cancer Center, New York City, April 2-4, 1992, 5.
(14) Coyle et al.
page 28 WHEN DEATH IS SOUGHT
PATIENTS WITH AIDS
Individuals with AIDS are far more likely to be suicidal than
the general population. One 1988 study conducted a postmortem
review of AIDS deaths in new York City and estimated that the
relative risk of suicide in men with AIDS aged 20 to 59 was 36 times
that of the general population.(15) In this study, most patients
with AIDS who committed suicide had a preexisting psychiatric
disorder. Another study found that the suicide rates for males with
AIDS were 7.4-fold higher than those among demographically similar
men in the general population.(16) Suicide reports indicate that
AIDS patients who commit suicide tend to act within nine months of
receiving a diagnosis of AIDS.(17)
Studies have also detected elevated rates of suicidal ideation
among groups at risk for human immunodeficiency virus (HIV)
infection, such as gay men and intravenous (IV) drug users.
Surprisingly, within these groups, suicidal ideation among those who
are H IV-positive is not higher than among those in the at-risk
group who have not been identified as HIV-positive. A recent study
of HIV-positive and HIV-negative individuals in the same population
showed that prior to notification of HIV status, the two groups
exhibited similar rates of suicidal ideation. Two months after
notification, no difference in frequency of suicidal thoughts or
attempts existed between those notified of a positive HIV test and
individuals informed of a negative result.(18) The rate of suicidal
ideation remained at over 15 percent for both groups. Researchers
have concluded therefore that HIV status alone may not account for
the high rates of suicidal ideation among AIDS patients. Instead,
preexisting psychological characteristics may place individuals in
the at-risk population for AIDS at a higher risk for suicidal
ideation. In fact, the study population had a higher rate of
current and lifetime depressive disorders and of substance abuse
than the general population.
-----------------------------------------------------------------------------
(15) P. M. Marzuk et al., "Increased Risk of Suicide in Persons
with aids," Journal of the American Medical Association 259
(1988): 1333-37.
(16) T. R. Cote, R. J. Biggar, and A. L. Dannenberg, "Risk of
Suicide Among Persons with AIDS: A National Assessment,"
Journal of the American Medical Association 268 (1992):
2066-68.
(17) Breitbart, "Suicide Risk and Pain," 55.
(18) Immediately after notification, the rate of suicidal
ideation among those who were HIV-positive remained stable at
27% (individuals did not become more suicidal upon
notification) and the rate of suicidal ideation among the
HIV-negative group dropped to 17%. However, after two months,
the HIV-positive group's rate fell to 16% - a level comparable
to the rate for HIV-negative individuals. S. Perry, L.
Jacobsberg, B. Fishman, "Suicidal Ideation and HIV Testing,"
Journal of the American Medical Association 26 3 (1990):
679-82.
CHAPTER 2 - SUICIDE AND SPECIAL PATIENT POPULATIONS page 29
Suicidal ideation may also be influenced by the patient's
perception of pain, stage of illness, and the patient's
psychological state. One study of ambulatory HIV-infected patients
discovered that suicidal ideation is highly correlated with the
presence o f pain, depressed mood, and low T4 lymphocyte counts.(19)
The study also found a strong connection between pain and emotional
distress. Twenty percent of HIV-infected patients without pain
reported suicidal ideation, compared to 40 percent of patients with
pain. Of the 110 patients in the study, only two reported serious
suicidal intent. However, the intent did not correlate with the
intensity of pain or extent of relief, but with mood disturbances
such as depression.
Organic mental disorders such as delirium and dementia are
important risk factors for suicide as AIDS progresses. Clinicians
have had success in treating delirium and reducing the levels of
suicidal ideation among aids patients. Depression is also a key f
actor. In one study in New York city of 12 patients with AIDS who
committed suicide, 50 percent were significantly depressed.
Preexisting personality disorders and history of suicidal attempts
or expression of suicidal thoughts can also heighten the risk of
suicide. Given the relatively recent appearance of AIDS and the
changing population of individuals with AIDS (most of the earliest
studies focused primarily on gay men), continued research must be
conducted to understand more fully the nature of suicide within this
patient population.
Patients with AIDS exhibit a range of pain symptoms similar to
that of patients with cancer. Studies have found that more than
half of patients with advanced AIDS experience significant pain.
Pain may arise from AIDS and related infections. AIDS therapy,
including antiviral agents, also causes side effects and discomfort.
Common types of pain arising from the disease and treatment include
abdominal pain, headache, joint pain, and peripheral neuropathy,
which may produce sensations of burning, numbness, or pins and
needles. Other physical symptoms include gastrointestinal
manifestations such as oral infections, difficulty swallowing, and
diarrhea.(20)
-------------------------------------------------------------------------
(19) Breitbart, "Suicide Risk and Pain."
(20) Ibid., 58-59; W. N. O'Neill and J. S. Sherrard, "Pain in
Human Immunodeficiency Virus Disease: A Review," Pain 54
(1993): 3-14.
page 30 WHEN DEATH IS SOUGHT
THE ELDERLY
Older age and physical illness are two risk factors for
suicide. Facing deteriorating health and increasing age, the
elderly are at a greater risk of suicide than any other age group.
Although the rates of suicide declined between 1950 and 1980 for
individuals over age 65, between 1980 and 1986, the rates increased
by approximately 21 percent.(21) Men accounted for 80 percent of all
deaths, and white males over 85 had the highest suicide rates for
all age groups.(22) The most common means of suicide among the
elderly was a gun (73 percent of the men, 29 percent of the women).
An overdose of drugs or poison was more common among women.
According to current estimates, the level of suicide among the
elderly will double over the next 40 years.(23)
The distinction between suicide attempters and completers that
is prominent for other age groups dissipates among the elderly
population. Unlike younger individuals, whose suicide attempt is
often a plea for help or indication of a need for a change in life
circumstances, older individuals who attempt suicide are generally
more likely to succeed. They also often use methods that are more
violent or lethal. In addition, suicide attempts by the elderly are
more clearly planned or premeditated.(24)
Risk factors for suicide, such as depression, alcoholism,
physical illness, and organic mental dysfunction, which impair
judgment and the ability to generate alternative options,(25)
contribute to the increased rates of suicide among the elderly.
Unlike younger suicidal individuals for whom a history of suicide
attempts, substance abuse, and mental illness play a major role, for
the elderly social isolation and physical disability are more
important variables.(26) Some data suggest that when older
individuals commit suicide, they are more likely to suffer from a
mood disorder than are younger individuals who commit suicide.(27)
Available clinical data estimate that a majority of elderly persons
who commit suicide suffer from depressive episodes.(28)
----------------------------------------------------------------------------
(21) P. J. Meechan, L. E. Saltzman, and R. W. Sattin, "Suicides
Among Older U.S. Residents: Epidemiologic Characteristics and
Trends," American Journal of Public Health 18 (1991):
1198-1200.
(22) Y. Conwell, M. Rotenberg, and E. D. Caine, "Completed
Suicide at Age 50 and Over," Journal of the American Geriatrics
Society 38 (1990): 640-44.
(23) G. L. Kennedy, "Depression in the Elderly," in Psychiatry
1993, ed. R. Michaels et al., vol. 2 (Philadelphia: J. P.
Lippincott, 1993), 1-11.
(24) S. B. Sorenson, "Suicide Among the Elderly: Issues Facing
Public Health," American Journal of Public Health 81
(1991):1109-10.
(25) Ibid.
(26) Kennedy.
(27) Conwell, Rotenberg, and Caine, 640-44.
(28) Kennedy, 8.
CHAPTER 2 -- SUICIDE AND SPECIAL PATIENT POPULATIONS page 31
Few studies have examined later-life suicides. Consequently,
researchers hold differing views about whether medical or
psychiatric disorders cause suicidal behavior among elderly
individuals, or whether factors such as social isolation or
inadequate social support are more significant.(29) In addition,
some argue that advances in medical care, which have prolonged the
lives of persons with chronic illness, have resulted in higher
suicide rates for elderly, chronically ill persons.(30)
While the prevalence of depressive symptoms increases with
age, the rate of major depressive disorders declines.(31) The
presence of depressive symptoms among the elderly ranges from a low
of 9 percent to a high of 19 percent.(32) One study found that as
many as 25 percent of elderly living in the community had depressive
symptoms.(33) Rates of clinical depression among elderly community
residents are similar to those for other age groups (under 3
percent).(34)
In contrast to rates of depression for elderly community
residents, the prevalence of major depression is high among elderly
nursing home residents, with estimates ranging from 6 percent to 25
percent. Approximately 30 percent to 50 percent of older residents
experience depressive symptoms.(35) Each year approximately 13
percent of residents develop a new episode of major depression and
another 18 percent develop new depressive symptoms. In addition,
half of nursing home residents suffer from dementing illnesses such
as Alzheimer's or vascular dementia and require treatment for
psychological symptoms, including depression.(36)
The high rates of depression among nursing home residents may
be due in part to social circumstances such as separation from
family and home and in part to illness and medications.
----------------------------------------------------------------------------
(29) G. L. Kennedy, "Suicide, Depression, and the Elderly,"
Presentation to the New York State Task Force on Life and the
Law, May 13, 1992.
(30) Meechan, Saltzman, and Sattin.
(31) D. G. Blazer, "Depression in the Elderly," New England Journal of
Medicine 320 (1989): 164-66.
(32) Kennedy,"Depression in the Elderly,."3.
(33) D. Blazer, D. C. Hughes, and L. K. George, "The
Epidemiology of Depression in an Elderly Community Population,"
Gerontologist 27 (1987): 281-87.
(34) National Institutes of Health Consensus Conference,
"Depression in Late Life," Journal of the American Medical
Association 268 (1992): 1018-24.
(35) Blazer, Hughes, and George, "Epidemiology of Depression."
(36) Psychotherapeutic Medication in the Nursing Home: Position
Statement," Journal of the American Geriatrics Society 40
(1992):946-49.
page 32 WHEN DEATH IS SOUGHT
Social and medical risk factors for depression in the elderly
are similar to other age groups. Some experts have also found that
older individuals are more likely than younger individuals to become
depressed following the death of a loved one. (37) Women are also
at increased risk for depression as they age. The presence of
symptoms necessary for a diagnosis of depression are also much the
same as for other age groups. The elderly may differ in that they
are more likely to lose weight and less likely to express feelings
of guilt or worthlessness.(38) Depression is widely underdiagnosed
and undertreated among the elderly. This occurs in part because
depression and other psychiatric disorders are often difficult to
recognize among elderly individuals. Typical symptoms such as
depressed mood may be less prominent, and other medical problems
also cause symptoms associated with depression, such as disturbed
sleeping patterns and loss of appetite. Health care professionals
often mistake depressive symptoms for normal signs of the aging
process or for dementia. A 1992 National Institutes of Health (NIH)
Consensus Development Panel on Depression in Late Life recognized
this confusion as a serious problem:
Because of the many physical illnesses and social and economic
problems of the elderly, individual health care providers often
conclude that depression is a normal consequence of these problems,
an attitude often shared by the patients themselves . All of these
factors conspire to make the illness underdiagnosed and, more
important, undertreated.(39)
A recent study of the treatment of depressed elderly nursing
home residents confirmed that inadequate diagnosis and treatment for
depression was pervasive. In one study that involved independent
evaluation of residents by a research psychiatrist, fewer than 15
percent of depressed residents had correctly been diagnosed by the
nursing home physician and fewer than 25 percent of those residents
had been treated for depression.(40) Other studies have also
reported underdiagnosis and undertreatment of depression; one study
noted that only 15 percent of the alert and oriented patients with
depression received treatment.(41)
------------------------------------------------------------------------
(37) Kennedy,"Depression in the Elderly."
(38) Blazer, "Depression in the Elderly," 164-66.
(39) NIH Consensus Development Panel on Depression in Late Life,
1018-24.
(40) B. W. Rovner et al., "Depression and Mortality in Nursing
Homes," Journal of the American Medical Association 265 (1991):
993-96.
(41) L. L. Heston et al., "Inadequate Treatment of Depressed
Nursing Home Elderly," Journal of the American Geriatrics
Society 40 (1992): 1117-22.
CHAPTER 2 -SUICIDE AND SPECIAL PATIENT POPULATIONS page 33
The elderly are also at risk for both the undertreatment and
overtreatment of pain. Cognitive impairment can make it difficult
for elderly patients to express their feelings of pain adequately.
Thus, pain is often overlooked by health care providers. Elderly
patients may also be overtreated for pain resulting from the
physiological changes that take place as individuals age. Because
the elderly have a decreased ability to metabolize certain
medications, they are more sensitive to analgesic effects of opioid
drugs. As a result, they experience higher peaks and a longer
duration of pain relief from the medication than younger patients.
Finally, side effects of pain medication, such as constipation,
urinary retention and respiratory depression, are also more common
among elderly patients.(42)
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(42) J. Addison, "Management of Pain in the Elderly,"
in Pain Management and Care of the Terminally Ill,
Washington State Medical Association, Washington State
Physicians Insurance, Washington State Cancer Pain
Initiative (Seattle: Washington State Medical Association,
1992), 205-14.
page 34 Intentionally Left Blank
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