Download Why Do Some Cancer Patients With Depression Desire an Early

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., YOSUKE UCHITOMI , M.D., PH.D.
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.
(Psychosomatics 2001; 42:141–145)
B
ecause 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.
Psychosomatics 42:2, March-April 2001
METHODS
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
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.
Copyright 䉷 2001 The Academy of Psychosomatic Medicine.
141
Desire for Death in Cancer Patients With Depression
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 psychooncology 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.
RESULTS
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
[meanⳲstandard deviation (SD)] age of these depressive
patients was 57.6Ⳳ11.7 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 (n⳱54, 24.5%), followed by the breast (n⳱32,
142
14.5%), and the stomach (n⳱20, 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
[beta⳱0.26; S.E.⳱0.12; odds ratio⳱1.29; 95% confidence interval (CI)⳱1.03–1.63; P⳱0.03] and severe depression (beta⳱0.59, S.E.⳱0.14, odds ratio⳱1.80; 95%
CI⳱1.39–2.37; P⳱0.0001) were significant risk factors.
In this multivariate analysis, employment status was not
statistically significant (beta⳱0.50; S.E.⳱0.31; odds ratio⳱1.65; 95% CI⳱0.91–3.02; P⳱0.10).
DISCUSSION
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 dePsychosomatics 42:2, March-April 2001
Psychosomatics 42:2, March-April 2001
56.6Ⳳ11.8
1.4Ⳳ1.1
1.2Ⳳ0.8
6.2Ⳳ1.0
50(47)
87(81)
45(42)
27(25)
61(57)
7(7)
1(1)
67(63)
58.5Ⳳ11.6
1.8Ⳳ1.4
1.4Ⳳ1.0
6.9Ⳳ1.2
47(42)
88(78)
31(27)
27(24)
72(64)
8(7)
3(3)
70(62)
Absence (nⴔ107)
meanⴣSD
218
ⳮ1.22
ⳮ1.97
ⳮ0.87
ⳮ4.77
1
—d
1
—d
0.01
1
1
1
1
1
df
t
0.03
1.03
0.05
5.20
0.59
0.40
v2
Analysis
Note: aDefined by Eastern Cooperative Oncology Group criteria.
b
Coded as 1⳱Not at all; 2⳱A little; 3⳱Tolerable; and 4⳱Intolerable.
c
Severity of depression is defined by the total number of diagnostic criteria present for major depression (excluding suicidal ideation) according to the DSM-IV.
d
This value was not calculated because Fisher’s Exact test was conducted.
Age, in years
Performance statusa
Painb
Severity of depressionc
Men, n(%)
Married, n(%)
Employment status, n(%)
Full or part time
Cancer site, n(%)
Lung
Advanced stage, n(%)
Recurrent or metastatic
Brain metastasis, n(%)
Presence
Psychotic features, n(%)
Presence
In-patients
Presence (nⴔ113)
meanⴣSD
Suicidal Ideation
Comparisons of background data on the presence of suicidal ideation for referred cancer patients with major depression
Characteristic
TABLE 1.
0.62
0.92
0.87
0.31
0.82
0.02
0.22
0.05
0.39
0.0001
0.44
0.53
P value
Akechi et al.
143
Desire for Death in Cancer Patients With Depression
pression 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.
Preliminary analysis was based on psychiatric consultation data from the Cancer Center Hospital in Japan.
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