Evidence-Based Strategies to Reduce Suicide Mortality Among Patients With Cancer

Abstract

Since 1999, the US suicide rate has increased by more than 30%. 1 Numerous studies have demonstrated that suicide mortality is elevated among people with cancer, especially cancers with lower 5-year survival. 2 In this issue of JAMA Oncology, Potter et al 3 report that patients who underwent surgery for cancers with lower 5-year survival also died of suicide much sooner than patients with less deadly cancers, implicating the importance of screening patients with cancer for psychiatric conditions and suicide risk. In addition, the data highlight the importance of ensuring access to evidence-based psychological and behavioral treatments both before and after cancer surgery. Approximately 1 in 6 patients have a preexisting psychiatric condition. 4 Apart from an association with suicide mortality, psychiatric conditions can adversely affect a range of outcomes, including increased perioperative complications, longer hospital stays, higher rates of readmission, and increased risk of postoperative suicidal ideation. 4,5 Preoperative or perioperative treatment of psychiatric conditions may therefore lead to improved outcomes.The National Comprehensive Cancer Network and the American Society of Clinical Oncology recommend universal screening for psychiatric conditions and elevated emotional distress among all patients with cancer. 6,7 In particular, distress should be monitored throughout the disease trajectory and in all care settings. 6,7 Although neither the National Comprehensive Cancer Network nor the American Society of Clinical Oncology specifically address suicide risk screening, patients screening positive for a psychiatric condition or elevated emotional distress should also be screened for suicidal ideation. Common barriers to suicide risk screening include lack of training or knowledge, lack of access to behavioral health resources, difficulty differentiating suicidal ideation from other facets of emotional distress, limited time with patients, and fears related to the implications of suicide risk screening results. 8 These barriers can be overcome through the use of evidencebased screening, assessment, and treatment strategies.Regarding screening, patients diagnosed with a psychiatric condition or who screen positive for elevated distress should also be screened for suicidal ideation using one of multiple validated tools, such as the Patient Health Questionnaire-9, Patient Safety Screener, Ask Suicide-Screening Questions, or Columbia Suicide Severity Rating Scale screener. Newer research indicates that supplementing these tools with the Suicide Cognitions Scale, a self-report scale that assesses extreme negative thoughts and beliefs like unbearability ("I can't imagine anyone being able to tolerate this pain") and unsolvability ("No one

Management of Anxiety and Depression in Adult Survivors of Cancer: ASCO Guideline Update

“…143,144 Crisis response planning should be readily implemented as a brief, practical strategy for reducing short-term suicide risk. 145 For any acutely suicidal patient, institutional management and referral policies should be followed.…”

Prognosis and risk of suicide after cancer diagnosis

“…However, uptake has been minimal, with only 46%–73% of patients being screened 40,41 . Addressing distress and improving management of depression in patients with cancer may improve cancer‐related outcomes, including quality of life, medication adherence, post‐surgical outcomes, and survival 6,30,36,38,42 …”

“…There are several validated tools for suicide risk screening. 30 However, predicting suicide may be difficult, as patients with cancer have a low ratio of self-harm events to fatal suicide events compared with those with other physical and psychiatric disorders. 6,31 Treating providers may choose to spend additional time with high-risk patients, because the patient-oncologist alliance is protective of suicidal ideation.…”

“…In addition to pharmacological therapy, cognitive behavioral therapy, problem-solving therapies, and crisis response planning have been shown to reduce suicidal behaviors in randomized controlled trials. 30 Completed suicides likely reflect a larger burden of cancerrelated psychiatric morbidity. It is estimated that there are approximately 20 suicide nonfatal attempts for each fatal suicide attempt.…”

“…40,41 Addressing distress and improving management of depression in patients with cancer may improve cancer-related outcomes, including quality of life, medication adherence, post-surgical outcomes, and survival. 6,30,36,38,42 Reasons for suicide in patients with cancer may include pain, poor quality of life, existential angst, and psychiatric illness or severe depressive symptoms, but may also stem from a desire or will for self-control. 8 It is important to distinguish the wish for self-autonomy from severe depression as the two etiologies may be addressed differently.…”