Psychosomatics 42:141-145, April 2001
© 2001 The Academy of Psychosomatic Medicine
Why Do Some Cancer Patients With Depression Desire an Early Death and Others Do Not?
Tatsuo Akechi, M.D., Ph.D.,
Hitoshi Okamura, M.D., Ph.D.,
Shigeto Yamawaki, M.D., Ph.D., and
Yosuke Uchitomi, M.D., Ph.D.
Received April 12, 2000; revised September 7, 2000; accepted October 25, 2000. From Psycho-Oncology Division, National Cancer Center Research Institute East; Psychiatry Division, National Cancer Center Hospital East; Psychiatry Division, National Cancer Center Hospital; and the Department of Psychiatry and Neurosciences, Hiroshima University School of Medicine. Address correspondence and reprint requests to Dr. Uchitomi, Psycho-Oncology Division, National Cancer Center Research Institute East, 6-5-1 Kashiwanoha, Kashiwa, 277-8577, Japan.
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ABSTRACT
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Major depression is a well-documented risk factor for suicide in cancer patients as well as in the general population. However, there are no data explaining why some cancer patients suffering from major depression have suicidal ideation, while others do not. The authors investigated the background differences among cancer patients suffering from major depression with and without suicidal ideation by analyzing the consultation data of patients referred to the psychiatry division. Among the 1,721 referred patients, 220 (12.8%) were diagnosed with major depression, and of these 113 (51.4%) had suicidal ideation. Logistic regression analysis indicated that poor physical functioning and severe depression were significant risk factors. These preliminary findings suggest that the severity of major depression and physical functioning are important indicators of suicidal ideation among cancer patients.
Key Words: Depression • Cancer • Suicidal Ideation
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INTRODUCTION
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Because cancer is a life-threatening illness, its psychological impact on patients is considered to be an important aspect of psycho-oncology. It is well known that one of the most common expressions of psychiatric disorders in cancer patients is depression.1,2 On the other hand, since euthanasia and physician-assisted suicide have emerged as important and urgent medical and social issues all over the world, there has been much interest in suicidal ideation or the request for an early death in cancer.3–6 Several factors, such as uncontrolled pain, advanced illness, loss of control, and hopelessness, have been suggested as indicators for vulnerability to suicide in cancer patients.7,8 In addition, depression is a well-documented risk factor for suicidal ideation and for suicide in cancer patients as well as in the general population.9,10 However, there are no data explaining why some cancer patients suffering from major depression have suicidal ideation, while others do not. The objective of the present study is to compare the differences in the background characteristics of cancer patients suffering from major depression who have suicidal ideation and those who do not.
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METHODS
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We reviewed all psychiatric consultations referred to the psychiatry divisions of the National Cancer Center Hospital and Hospital East in Japan from July 1996 to December 1999. A computerized database was used to identify the risk factors for suicidal ideation. The database included demographic factors, medical factors, and psychiatric diagnosis and interviews according to the DSM-IV. Performance status was obtained from patients charts or interviews by psychiatrists. It is defined by Eastern Cooperative Oncology Group criteria as an objective index of a patient's physical functioning, ranging from 0 (No Symptoms) to 4 (Bedridden).
The diagnosis of major depression was made using a structured clinical interview based on the DSM-IV. The nine diagnostic criteria for major depression, which include suicidal ideation, were also included in the database. When a criterion was assessed as absent or subthreshold, it was entered as absent in the database, and when assessed as present, it was entered as present in the database. With regard to the diagnosis of major depression, the original DSM-IV diagnostic criteria excluded symptoms that may be attributable to the general medical condition. Because differential diagnosis is often impossible and the etiological diagnostic approach is not considered useful in psycho-oncology practice, we modified the original DSM-IV diagnostic approach and adopted the inclusive approach, which is based on depressive symptomatology regardless of presumed etiology.11
Patient sheets completed by psychiatrists were automatically read by a mark sheet reader and preserved in the database.
Only the data of patients diagnosed as having major depression were extracted from the database. These patients were divided into two groups according to the presence or absence of suicidal ideation. To study the risk factors for suicidal ideation, background data (age, gender, marital status, employment status, cancer site, disease stage, performance status, brain metastasis, in- or out-patient status, pain, severity of depression, and psychotic features) were compared between the two groups using univariate analysis. In this study, we defined severity of depression as the number of diagnostic DSM-IV criteria present, except for suicidal ideation. The final risk factors were determined by logistic regression analysis, including variables having a P-value of <0.10 according to the univariate analysis. All P values were two-tailed. All data analyses were conducted using SAS statistical software.
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RESULTS
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Patient Demographic and Medical Characteristics
A total of 1,721 cancer patients were referred during the study period. Of that number, 220 patients (12.8%) were diagnosed as having major depression. Of the patients with major depression, 113 (51.4%) had suicidal ideation. The [mean±standard deviation (SD)] age of these depressive patients was 57.6±11.7 years; 123 (55.9%) were women, 137 (62.3%) were inpatients, 67 (30.5%) were employed full-time, 9 (4.1%) were employed part-time, and 175 (79.5%) were married. The most frequent cancer site was the lung (n=54, 24.5%), followed by the breast (n=32, 14.5%), and the stomach (n=20, 9.1%). Sixty-seven patients (30.5%) were diagnosed as having metastatic cancer, and 66 (31.1%) had experienced recurrence. Fifteen (6.8%) had brain metastasis. Twenty-five patients (11.4%) had a performance status of 4, and 27 (12.3%) had a performance status of 3. All patients, except for 1 (0.5%), had been informed of their cancer diagnosis.
Risk Factors for Suicidal Ideation
Comparisons of patients with major depression with and without suicidal ideation are shown in Table 1. Univariate analysis showed that poor performance status, severe depression, and employment status (without full-time and/or a part-time job) were significant risk factors for suicidal ideation. There were no significant correlations among these three factors. Logistic regression analysis including these three factors revealed that performance status [beta=0.26; S.E.=0.12; odds ratio=1.29; 95% confidence interval (CI)=1.03–1.63; P=0.03] and severe depression (beta=0.59, S.E.=0.14, odds ratio=1.80; 95% CI=1.39–2.37; P=0.0001) were significant risk factors. In this multivariate analysis, employment status was not statistically significant (beta=0.50; S.E.=0.31; odds ratio=1.65; 95% CI=0.91–3.02; P=0.10).
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TABLE 1. Comparisons of background data on the presence of suicidal ideation for referred cancer patients with major depression
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DISCUSSION
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This is the first preliminary study that provides information about risk factors for suicidal ideation in cancer patients with major depression. The results of this study show that more than half (51.4%) of the referred cancer patients with major depression suffered from suicidal ideation. Because the subjects of our study were patients who had been referred to the psychiatry division, the sampling bias may be problematic. However, the rate of prevalence of suicidal ideation may not be low, and the rate we identified is similar to that indicated in prior studies investigating the prevalence of suicidal ideation among patients with major depression in a psychiatric setting.12
The present study provides a clue to understanding why some cancer patients with major depression have suicidal ideation and others do not. Univariate analysis indicated that poor performance status, employment status, and severe depression were possible risk factors for suicidal ideation, despite the lack of a significant association between suicidal ideation and important factors such as marital status and pain.7–9 Previous studies investigating risk factors for suicide in noncancer patients with major depression listed a number of significant suicide-related factors, including a previous suicide attempt, being unmarried, living alone, hopelessness, personality (low introversion), neurovegitative signs, severity of depression, and comorbidity of alcoholism.13–17 Those studies suggested that several different dimensions, including biological, psychological, and social factors, enhanced suicidal tendencies among patients with major depression. Because the present study did not include all of these factors, it is impossible to simply compare the findings with those of previous studies. Further investigation will be needed to clarify whether risk factors for suicidal ideation differ between cancer patients and noncancer patients with major depression.
Our findings show that cancer patients with major depression who are not engaged in full- or part-time employment, who have a poor performance status, and who have more severe depression should be carefully and intensively monitored to prevent suicide. Multivariate analysis showed that only poor physical functioning and severity of depression were significant risk factors. The significant association between suicidal ideation and severity of depression seems reasonable, and severe major depression may be an important clinical indicator of suicidal ideation in cancer patients. As for physical functioning, several studies have indicated that performance status is one of the more significantly associated factors of depression in cancer patients.18,19 Thus, physical functioning seems to be an important risk factor for suicidal ideation as well as depression.
The physician-assisted suicide practice in Oregon suggested that loss of control of bodily functions is an important reason for requesting assistance with suicide.3 Our previous study indicated that performance status is a significant factor predicting a deleterious mental adjustment to cancer (helplessness/hopelessness).20 Thus, a patient's mental adjustment to cancer might serve as a mediator between physical functioning and suicidal ideation, although further study is needed to clarify this association.
This preliminary retrospective study has several limitations. Some important information, such as physical distress other than pain, past history of suicide ideation, past history of depression, anxiety, feelings of loss of control, social support, and individual coping style, were not included. The definition of severity of major depression may have been problematic because the severity is usually decided by striking a balance between the number and intensity of symptoms. In addition, the referred patient sample may have been influenced by physician bias.
Further research is needed to study why some cancer patients with major depression have suicidal ideation and others do not. As the clinical outcome of suicidal ideation after psychiatric consultation would also be informative, we have been studying the clinical course of suicidal ideation in cancer patients with major depression after psychiatric intervention.
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ACKNOWLEDGMENTS
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Preliminary analysis was based on psychiatric consultation data from the Cancer Center Hospital in Japan.
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REFERENCES
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ABSTRACT
INTRODUCTION
