Chapter 2 - Suicide and Special Patient Populations

				  CHAPTER 2			page 23



	  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),


    page 24		  WHEN DEATH IS SOUGHT


	  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


	  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.


    (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.


	  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


	  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.


	  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.


	  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


	  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


	  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):


   (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):



	  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



   (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


	  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):


   (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


   (25)  Ibid.

   (26)  Kennedy.

   (27)  Conwell, Rotenberg, and Caine, 640-44.

   (28)  Kennedy, 8.


	  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


	  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


    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,


   (40)	  B.  W. Rovner et al., "Depression and Mortality in Nursing

	  Homes," Journal of the American Medical Association 265 (1991):


   (41)	  L.  L. Heston et al., "Inadequate Treatment of Depressed

	  Nursing Home Elderly," Journal of the American Geriatrics

	  Society 40 (1992):  1117-22.


	  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)


    (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.

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