Review of completed suicide and suicidal ideation in oncologic patients from a geographic classification

Revisión de suicidios completados e ideación suicida en pacientes oncológicos con distribución geográfica

Daniel Diaz-Frutos1,2, Enrique Baca-Garcia1, Jesus Garcia-Foncillas2, Pablo Méndez Bustos3

1. Department of Psychiatry and Clinical Psychology, Fundación Jiménez Díaz Hospital, Autonoma University of Madrid, (UAM), Spain.

2. Department of Oncology, Fundación Jiménez Díaz Hospital, Autonoma University of Madrid, (UAM), Spain.

3. Universidad Católica del Maule. Chile.

Resumen

El riesgo de suicidio en oncología es casi dos veces mayor que en la población general, principalmente asociado a trastornos de salud mental y al diagnóstico. A través de una búsqueda bibliográfica en MEDLINE, PsycINFO, ISOC y CISNE llevada a cabo entre el 2004-2015, se reportaron 823 artículos de los cuales, se revisó su relevancia a partir del resumen del artículo. Dos ciento quince artículos fueron identificados como relevantes y después de aplicar los criterios de inclusión y exclusión, 68 artículos se incluyeron en la revisión. El riesgo de comportamientos suicidas fue mayor en los Estados Unidos, Suecia y Corea del Sur. Principalmente en los hombres, con métodos más violentos de suicidio, la edad (adultos jóvenes y mayores >60), con tumores en la próstata, pulmón, páncreas, cabeza y cuello. Se encontró una alta prevalencia de comportamientos suicidas en la población con cáncer, sin embargo, las diferencias entre países demuestran lo poco que se ha investigado sobre los factores de riesgo.

Palabras clave: Suicidio; Ideación suicida; Intento de suicidio; Cáncer; Salud mental.

Abstract

The risk of suicide in oncology is almost two times higher than in the general population, mainly associated to mental health disorders and diagnosis. A literature search of MEDLINE, PsycINFO, ISOC and CISNE between 2004-2015, yielded 823 articles of which the abstract were reviewed for their relevance. Two hundred fifteen articles were identified as relevant and following application of inclusion and exclsuion criteria, 68 articles were included in the review. The suicide behaviors risk was higher in the USA, Sweden and South Korea. Mainly in men, with more violent methods of suicide, age (young adults and older>60), with prostate, lung, pancreas, head and neck tumors. There was high prevalence of suicidal behaviors in cancer population, however the differences between countries show how little risk factors has been researched.

Key words: Suicide; Suicide ideation; Suicide attempt; Cancer; Mental health.

Introduction

Cancer and suicide behaviors are considered life-threatening events causing million of deaths worldwide (Quill, 2008; Spoletini et al., 2011). In Europe, cancer is a leading cause of death with 1.5 million deaths (Malvezzi, Bertuccio, Levi, La Vecchia, & Negri, 2013; Torre et al., 2015). And, there are between 3 and 31.5 suicides every 100,000 persons (Hoven, Mandell, & Bertolote, 2010). Risk factors in general population can be applied to oncologic populations (Robson, Scrutton, Wikinson & MacLeod, 2010) i) gender, women have higher risk of suicide attempts than men, as well as higher levels of suicidal ideation and passive methods of suicide (Aghanwa, 2004) meanwhile men have higher risk of completed suicide and active lethal methods (Beautrais, 2003). ii) Age, young and old adults have a high risk of completed suicides, especially with socioeconomical problems (Carroll-Ghosh, 2003; Sudak, 2005). iii) The range of suicides of people with mental illnesses is 47%-74% , especially major depression and psychotic disorders (Nock, Hwang, Sampson, & Kessler, 2010).

Oncologic patients, and especially those in palliative situation, may have high levels of distress and mental disorders during illness process, especially anxiety and depression (Holland & Alici, 2010; Diaz-Frutos, Baca-García, García-Foncillas & López-Castroman, 2016). The prevalences of depression and anxiety in oncologic patients are 50% and 40%, respectively (Chochinov, 2001; Massie, 2004; Mitchell et al., 2011; Walker et al., 2014). However, around 10% of oncologic patients are referred to mental health professionals, hence the undermining of psychological problems may increase the risk of suicide behaviors (Holland & Alici, 2010; Weinberger, Bruce, Roth, Breitbart, & Nelson, 2011). There is a high risk of suicidal behaviors in oncologic patients, for instance, suicidal ideation is ranged around 10%-40% and completed suicides are twice than in the general population (Misono, Weiss, Fann, Redman, & Yueh, 2008). Other relevant risk factors are substance abuse (Botega et al., 2010; Passik & Theobald, 2000), bipolar disorders, psychotic disorders and personality disorders that may affect the adherence to treatments and survival of the patients (Chang et al., 2014; Miovic & Block, 2007; Tseng, Chang, Liao, Chen, & Lee, 2010) and the distress or psychological problems after surviving the cancer (Lu et al., 2013; Recklitis, Diller, Li, Najita, , Robison, & Zeltzer, 2010). This review aims at exploring the current literature to address the reported incidence and rates of suicide behaviors in cancer patients geographically. Moreover, this paper focus on identified risk factors related to suicide behaviors and cancer to overcome previous limitations (Robson, et al. 2010).

Methods

Out search strategy included the following databases Medline, Pubmed, PsycInfo, Web of Science and ISOC/CISNE (spanish databases) searched between January 2004 and April 2015, using keywords (spanish-english): “cáncer-cancer”, “suicidio-suicide”, “ideación suicida-suicide ideation”, “intento suicida-suicide attempt”, “conductas suicidas-suicidal behaviors”, we did not exlude any age or type of cancer or suicide behaviour. Search results were merged and duplicate studies removed to produce one set of results with 823 articles. The abstracts of these 823 articles were reviewed for their relevance to the current review. This produced 215 articles for review,  68 of which met the inclusion criteria: papers within the specified 11-year period, written in english or spanish, the population of study was oncologic patient, the subject of study was completed suicide, suicide attempt or suicidal ideation risk, the sample size was greater than 10 and  1 or more of the variables associated with cancer and suicide such as gender, age, type, site of cancer, risk factors including psychological and clinical (time of diagnosis, treatment and prognosis), and country of origin.

Results

Major findings were completed suicides and suicidal ideation and the following risk factors: country, type of tumor, gender, age, depression, time from diagnosis, time of hospitalization, and other sociodemographic and clinical variables (employment, education, religion…). Following, we have included the percentage of papers by every country and the incicende/prevalence of suicide behaviours in each country. Although the methodology and study population vary greatly, we present data from the reviewed papers in order of  relevance in the text and year in the tables.

Completed suicide in oncologic patients

This review shows that 34.9% of the articles were from the USA, 44.2% Europe, 11.6% Asia and 2.3% Iberoamerica (Table 1). The reported incidence of suicide in the USA was 31.4 every 100,000 especially during the first 5 years after diagnosis (Fang, Keating, Mucci, Adami, Stampfer, Valdimarsdóttir, & Fall, 2010; Johnson et al., 2012; Ward et al., 2013). In Canada, a high risk of suicide was found in the first three months after diagnosis (Chung & Lin, 2010; Lin, Wu, & Lee, 2009) as well as in Taiwan (Chung & Lin, 2010; Lin et al., 2009). Especially high levels of completed suicide in oncologic patients have been found in South Korea during the first year of diagnosis (Ahn et al., 2010). In Europe, the stimated rates vary between 1.3 and 16 depending on origin, type of tumor and time after diagnosis (Fall et al., 2009; Fang, Fall, Mittleman, Sparén,  Ye, Adami,  & Valdimarsdóttir, 2012; Yousaf, Christensen, Engholm, & Storm, 2005). Scandinavian countries, especially Sweden have the highest prevalences in Europe (Fang et al., 2012).

Table I. Completed suicide in oncologic patients

SMR, standardized mortality ratio; OR, Odds ratios; HR, hazard ratio; RR, relative risk; SIR, standardized incidence ratios; IRR, incidence rate ratio

Accordingly, the type of cancer (lung, head, neck, oral, gynecologic and pancreas) is a risk factor of completed suicide (Dormer, et al., 2008; Kendal & Kendal, 2012; Mahdi et al., 2011; Misono et al., 2008). Males, under 18 or over 60, unemployed, without religious beliefs and without social support have higher risk of suicide and violent methods (Chun & Lin, 2010; Kendal, 2007; Lin, Wu, & Lee, 2009; Panczak et al., 2013; Robinson et al., 2009). The first year of diagnosis is extremely crucial (Dormer et al., 2008; Hem et al., 2004; Mahdi et al., 2011; Robinson et al., 2009) especially with advanced cancer (Alanee & Russo, 2012; Fang et al., 2012; Mahdi et al., 2011; Yamauchi et al. 2014) and other medical illnesses (Bolton, Walld, Chateau, Finlayson, & Sareen, 2015) or mental health illnessess (Fang et al., 2012; Fanger et al., 2010; Hultcrantz et al. 2015; Llorente et al., 2005; Miller et al., 2008; Tseng et al. 2010). Finally, the first month after diagnosis is a crucial moment for preventive propose or treatment (Holland & Alici, 2010; Miovic & Block, 2007; Misono, Weiss, Fann, Redman, & Yueh, 2008; Robson, Scrutton, Wilkinson, & MacLeod, 2010).

Suicidal ideation in oncologic patients

This review shows that 30.7% of the articles are from the USA, 42.3% Europe, 11.5% Asia and 7.7% Iberoamerica (Table 2). The prevalence of suicidal ideation in oncologic patients in the USA is around17.7% (Schneider & Shenassa, 2008). In Europe between a 7%- 25% of the patients had suicidal ideation (Costantini et al., 2014; Eskelinen, Korhonen, Selander, & Ollonen, 2015; Jokinen, Mattsson, Lagergren, Lagergren, & Ljung, 2015; Spencer, Ray, Pirl, & Prigerson, 2012; Walker et al., 2008; Díaz-Frutos, Baca-García, Mahillo-Fernández, García-Foncillas & López-Castroman, 2015), in  Mexico was around a 20% (Vargas-Mendoza, 2010) and Brasil a 7 % (Botega et al., 2010; Fanger et al., 2010).

Table II. Suicidal ideation and suicide attempt in oncologic patients

SMR, standardized mortality ratio; OR, Odds ratios; RR, relative risk; SIR, standardized incidence ratios; IRR, incidence rate ratio

As it happens with completed suicide, there is a higher risk of suicidal ideation in determined types of tumor such as brain, lung, pancreas, breast, prostate and liver (Aketchi, et al., 2010; Jokinen et al. 2015; Kendal & Kendal, 2015; Recklitis, et al. 2010; Spencer, et al. 2012). Age, gender, socioeconomic status, … are as well as relevant risk factos that may undermine patients´alternatives for seeking or receiving treatment (Akechi et al., 2010; Kim,  Jang, Stewart, Kim, Kim, Kang, et al., 2013; Lehuluante & Fransson, 2014; Rasic, Belik, Bolton, Chochinov & Sareen, 2008; Recklitis et al., 2010). Finally, mental health issues, such as depression and hopelessness (Díaz-Frutos, et al. 2015; Kim et al., 2013; Rasic et al., 2008; Spencer et al., 2012) or the worsening of quality of life (Lehuluante & Fransson, 2014; Fang, et al. 2014; Rasic et al., 2008; Recklitis et al., 2010) are high risk factors for suicidal ideation.

Discussion

Oncologic patients have approxiamtely twice of risk of suicide behaviors than the general population, overall patients with lung, pancreas, prostate, stomach, breast and head and neck cancers (Misono et al., 2008; Robson et al., 2010). The completed suicide rates ranged from 1.2 to 16 from different countries, noticing most studies are from the USA and that Scandinavian and Eaester European countries show the highest levels of suicide behaviours. It is evident in the general population (Nock et al., 2008; Nock et al., 2010)  and in oncologic patients, that most of the risk factors of suicide behaviors are shared such as adult age, single status, low economical and educative status, psychiatric history or psychological factors (hopelessness, anxiety, depression, etc) or gender, affecting the making decisions process. Furthermore that completed suicide is not always conscutive to suicidal ideation, when those risk factors are taken into consideration (Aketchi, et al. 2010; Kendal et al. 2007). For instance, when men used more agressive methods to complete the act of suicide they do not always process thoughts or emotions (suicidal ideation) to make the decission, impulsivity may prevail (Chung & Lin, 2010). The review has stablished that the 5 years after cancer diagnosis, patients have more risk of suicide behaviors specially during the diagnosis and the last phase of life, advanced cancer patients may show high levels of psychological distress when receiving palliative treatments or lacking palliative care on different areas (Camidge et al., 2007). We found that most of the published data are from english speaking countries, USA and North european countries tend to produce more works and take higher interest on the health system costs and investments (García-Conde, Ibáñez-Guerra, & Durá-Ferrandis, 2008) hence the productivity of iberoamerican countries is very limited, however social health systems and family support may be affecting their results (Palacios-Espinosa & Ocampo-Palacio, 2011). These findings highlight the need for professionals to have a better understanding of differences between countries so that they can identify the risk factors in different populations that are migrating. And to ensure quality in their treatments when considering the patients needs.

The literature is not conclusive as to the effects of suicide behaviors in cancer. Many studies use collected data from national registers: Surveillance, Epidemiology, and End Results (SEER), and deaths or risk factors are not accurately classified. Because of the diverse methodology reviewed, it was not possible to use formal criteria to classify the assessment tools and how they affected the studies´results. Furthermore, we included studies with different sample sizes ranging from 10, to which is important caution when interpreting the data.  We have found more data about marital status, socioeconomic factors, ethnicity and mental health issues than in previous studies (Robson, et al. 2010). Our data suggest that the experiences of oncologic patients deservers further attention, particularly to provide appopriate interventions. The role of psychological factors and comorbidity invites further investigation to elucidate the relationship between phisical and psychiatric illnesses.

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