Suicidal (Assessment, Risk, & Prevention)
Suicide is a tragic event that shortens one life and can devastate both loved ones and health care teams. In 2020, 45,979 Americans died by suicide, making suicide the 12th leading cause of death in the United States1. Further, in that same year, there were an estimated 1.2 million suicide attempts. The suicide rate among cancer patients is 4.4 times higher that of the general population, at 28.58/per 100,000-person years2. Worse, the frequency of unreported and undetected suicides, or the degree to which cancer treatment nonadherence or refusal represents a form of suicide, suggests that the true incidence of suicide among people with cancer is probably underestimated.
Given this high prevalence, clinicians need to be attentive to identifying patients at risk and ensuring adequate safety measures and provision and care.
A comprehensive clinical approach to the problem of suicide in the oncology setting includes:
- Identifying patients at elevated risk of suicide including vulnerable subgroups within a population.
- Deploying targeted suicide risk prevention interventions that are both feasible and efficacious.
- Treating the underlying physical and psychological conditions contributing to the clinical presentation.
RISK FACTORS AND VULNERABLE SUBGROUPS
Cancer patients who die by suicide are more likely to be elderly, white, and unmarried males and diagnosed with either cancer of the lung, head and neck, testes, or Hodgkin lymphoma. Younger age and metastatic/distant disease at the time of diagnosis confers additional risk. For the majority of cancer types, the risk of completed suicide was higher within the first year after diagnosis2.
Individual risk factors that predict suicide are relatively non-sensitive and non-specific, and the clinical presentation varies widely. Patients at the highest risk include those who have previously attempted suicide, express suicidal thoughts or intent, and report suicidal thoughts or intent, or whose actions suggest a suicide attempt despite denying it. Additional individual risk factors include comorbid psychiatric disorders, substance abuse, impulsivity, social isolation, recent losses, and access to lethal methods (e.g., possession of firearms). Suicidality in cancer patients can be driven by a heavy symptom burden, reduced physical capacity, feelings of hopelessness, demoralization, and loss of meaning.
IDENTIFYING AT RISK PATIENTS
Early detection of patients at high risk for suicidal behavior is critical. The predictive value of screening tools for suicide falls short of ideal; nonetheless, initiatives to address suicide prevention recommend suicide risk screening in medical populations, as these can trigger helpful clinical interventions.
Routine screening for cancer-related distress should be part of the standard of care for all oncological patients and it can help identify those patients who may require more clinical attention. Tools that can help detect and stratify suicidal risk include the Patient Health Questionnaire (PHQ-9) and the Beck Hopelessness Scale (BHS). Finally, evidence-based suicide risk questionnaires, like the Columbia Suicide Risk Assessment (C-SSRS) and the Ask Suicide-Screening Questions (ASQ)6, are feasible interventions that can be incorporated into routine patient care.3 Table 1 lists different available suicide screening tools.
Table 1: Suicide screening tools |
|
Patient Health Questionnaire (PHQ-9) Beck Hopelessness Scale (BHS) SAD PERSONS Scale Manchester Self-Harm Rule (MSHR) Columbia Suicide Risk Assessment (C-SSRS) Ask Suicide-Screening Questions (ASQ) |
Click here to view table as PDF
CLINICAL ASSESSMENT AND MANAGEMENT OF HIGH RISK
A patient at risk for suicide should have a full clinical assessment that includes patient and family histories of suicide, prior suicidal attempts, psychiatric disorders (especially depression), and misuse of drugs or alcohol. Clinicians should ask about suicidal thoughts, plans, intent, and access to lethal means, such as a gun in the house or unused medications. Contrary to common beliefs, inquiring about suicide does not increase the risk for suicide.
In any psychiatric emergency, the primary goal is to ensure the patient’s safety. Patients who have expressed serious thoughts, plans, or behavioral indications about suicide require an immediate psychiatric evaluation.
Outpatients must be brought from their current location to the nearest emergency department for evaluation and safety measures. Oftentimes, calling 911 or activating emergency medical services is most expedient. In an emergency, family members should be informed of suicide risk and lethal items should be removed from or secured in the home. An acute psychiatric evaluation in the emergency setting determines the patient’s need for psychiatric care, whether enhanced outpatient support, voluntary, or involuntary inpatient psychiatric hospitalization. Some patients may be too medically ill for psychiatric units and require admission to medical floors along with psychiatric consultation and co-management.
Suicidal inpatients must be immediately placed under constant one-to-one safety observation while the team implements the hospital’s standard suicide safety measures. Often, this includes a room search for potential means of self-harm. While this is underway, the team must obtain an urgent psychiatric assessment to determine appropriate psychiatric treatment. For recommendations, see table 2.
Table 2: Emergent safety measures for acutely suicidal oncology patients |
|
| Outpatients |
● Emergent risk assessment and psychiatric evaluation ○ If immediately available, this can be done by outpatient psychiatry. ○ If not, ensure the patient or the patient’s family brings the patient to the nearest emergency department. ○ A member of the medical team may need to escort the patient to the emergency department if in a connected facility. ○ If this is not feasible, call 911/emergency medical services to have the patient evaluated at the nearest emergency department. ○ For patients at home, a safety check facilitated by law enforcement may be necessary in the event the patient is unwilling to seek care voluntarily. |
| In ED Triage |
● If suicidal thoughts occur in the context of an acute medical condition or related to a medication adverse effect, the patient will likely require a medical admission with constant 1:1 observation. ● If the suicidal crisis is not due to medical condition or medication, the patient will likely require inpatient psychiatric hospitalization. |
| Inpatients |
● Constant 1:1 observation from the time suicidal thoughts are expressed. ● Follow hospital suicide safety protocols, including room searches for available means for self-harming behavior. ● Urgent psychiatric evaluation. |
Click here to view table as PDF
INTERVENTIONS FOR REDUCING SUICIDE RISK
Education and Supportive Care: Education can increase awareness about suicide risk factors, reduce stigma and facilitate access to interventions. Ensure that patients are familiar with the National Suicide Prevention Lifeline (1-800-273-TALK (8255) or the Suicide and Crisis Lifeline (988), these resources can be life-saving during a crisis. Supportive care strategies that increase psychosocial support and improve physical and mental well-being can effectively reduce suicide risk by addressing pain, disability, depression, and isolation.
Psychotherapy: Supportive psychotherapy, cognitive behavioral therapy, and dialectical behavioral therapy are evidence-supported interventions that reduce suicide risk, depressive symptoms and psychological distress4. Interventions such as behavioral activation and problem-solving psychotherapy have also been specifically helpful in improving depression and reducing hopelessness and suicide in cancer populations.5
Pharmacologic considerations: Treatment of underlying psychiatric and medical disorders is critical to reducing suicide risk. Given the overall complexity of suicidal cancer patients, awareness of the effects of certain medications on existing medical symptoms, adverse effects, and drug-drug interactions is necessary, and we recommend prompt consultation with a psychiatric provider (psychiatrist/ psychiatric advanced practice nurse) when considering instituting a pharmacologic treatment. Specific medication recommendations are beyond the scope of this publication.
CONCLUSION
Suicide rates are higher in patients with cancer compared to the general population. Specific drivers of suicide in cancer patients, such as medical comorbidity, hopelessness, demoralization, existential distress, loss of coping mechanisms, and uncertainty contribute to a more challenging suicide assessment. An institutional strategy that includes standardized screening measures and a low threshold for urgent or emergent psychiatric assessment helps reduce risk among vulnerable patients. A treatment approach that combines medical optimization, psychotherapy, and psychopharmacology optimally relieves suffering and promotes wellness.
REFERENCES
- https://afsp.org/suicide-statistics/
- Zaorsky, N.G., Zhang, Y., Tuanquin, L. et al. Suicide among cancer patients. Nat Commun 10, 207 (2019). https://doi.org/10.1038/s41467-018-08170-1
- McFarland DC, Walsh L, Napolitano S, Morita J, Jaiswal R. Suicide in Patients With Cancer: Identifying the Risk Factors. 2019;7.
- D’Anci KE, Uhl S, Giradi G, Martin C. Treatments for the Prevention and Management of Suicide: A Systematic Review. Ann Intern Med. 2019 Sep 3;171(5):334.
- Hopko D. R. Funderburk J. S. Shorey R. C. McIndoo C. C. Ryba M. M. File A. A., et al. Vitulano M. (2013). Behavioral activation and problem-solving therapy for depressed breast cancer patients: Preliminary support for decreased suicidal ideation. Behavior Modification, 37(6), 747–767.
- https://www.nimh.nih.gov/research/research-conducted-at-nimh/asq-toolkit-materials
Risk Factors and Vulnerable Subgroups:
Cancer patients who die by suicide are more likely to be elderly, white, and unmarried males and diagnosed with either cancer of the lung, head and neck, testes, or Hodgkin lymphoma. Younger age and metastatic/distant disease at the time of diagnosis confers additional risk. For the majority of cancer types, the risk of completed suicide was higher within the first year after diagnosis2.
Individual risk factors that predict suicide are relatively non-sensitive and non-specific, and the clinical presentation varies widely. Patients at the highest risk include those who have previously attempted suicide, express suicidal thoughts or intent, and report suicidal thoughts or intent, or whose actions suggest a suicide attempt despite denying it. Additional individual risk factors include comorbid psychiatric disorders, substance abuse, impulsivity, social isolation, recent losses, and access to lethal methods (e.g., possession of firearms). Suicidality in cancer patients can be driven by a heavy symptom burden, reduced physical capacity, feelings of hopelessness, demoralization, and loss of meaning.
Identifying at Risk Patients:
Early detection of patients at high risk for suicidal behavior is critical. The predictive value of screening tools for suicide falls short of ideal; nonetheless, initiatives to address suicide prevention recommend suicide risk screening in medical populations, as these can trigger helpful clinical interventions.
Routine screening for cancer-related distress should be part of the standard of care for all oncological patients and it can help identify those patients who may require more clinical attention. Tools that can help detect and stratify suicidal risk include the Patient Health Questionnaire (PHQ-9) and the Beck Hopelessness Scale (BHS). Finally, evidence-based suicide risk questionnaires, like the Columbia Suicide Risk Assessment (C-SSRS) and the Ask Suicide-Screening Questions (ASQ)6, are feasible interventions that can be incorporated into routine patient care.3 Table 1 lists different available suicide screening tools.
| Table 1: Suicide screening tools | |
|
Patient Health Questionnaire (PHQ-9) Beck Hopelessness Scale (BHS) SAD PERSONS Scale Manchester Self-Harm Rule (MSHR) Columbia Suicide Risk Assessment (C-SSRS) Ask Suicide-Screening Questions (ASQ) |
|
Clinical Assessment and Management of Hight Risk:
A patient at risk for suicide should have a full clinical assessment that includes patient and family histories of suicide, prior suicidal attempts, psychiatric disorders (especially depression), and misuse of drugs or alcohol. Clinicians should ask about suicidal thoughts, plans, intent, and access to lethal means, such as a gun in the house or unused medications. Contrary to common beliefs, inquiring about suicide does not increase the risk for suicide.
In any psychiatric emergency, the primary goal is to ensure the patient’s safety. Patients who have expressed serious thoughts, plans, or behavioral indications about suicide require an immediate psychiatric evaluation.
Outpatients must be brought from their current location to the nearest emergency department for evaluation and safety measures. Oftentimes, calling 911 or activating emergency medical services is most expedient. In an emergency, family members should be informed of suicide risk and lethal items should be removed from or secured in the home. An acute psychiatric evaluation in the emergency setting determines the patient’s need for psychiatric care, whether enhanced outpatient support, voluntary, or involuntary inpatient psychiatric hospitalization. Some patients may be too medically ill for psychiatric units and require admission to medical floors along with psychiatric consultation and co-management.
Suicidal inpatients must be immediately placed under constant one-to-one safety observation while the team implements the hospital’s standard suicide safety measures. Often, this includes a room search for potential means of self-harm. While this is underway, the team must obtain an urgent psychiatric assessment to determine appropriate psychiatric treatment. For recommendations, see table 2
| Table 2: Emergent safety measures for acutely suicidal oncology patients | |
| Outpatients |
● Emergent risk assessment and psychiatric evaluation ○ If immediately available, this can be done by outpatient psychiatry. ○ If not, ensure the patient or the patient’s family brings the patient to the nearest emergency department. ○ A member of the medical team may need to escort the patient to the emergency department if in a connected facility. ○ If this is not feasible, call 911/emergency medical services to have the patient evaluated at the nearest emergency department. ○ For patients at home, a safety check facilitated by law enforcement may be necessary in the event the patient is unwilling to seek care voluntarily. |
| In ED Triage |
● If suicidal thoughts occur in the context of an acute medical condition or related to a medication adverse effect, the patient will likely require a medical admission with constant 1:1 observation. ● If the suicidal crisis is not due to medical condition or medication, the patient will likely require inpatient psychiatric hospitalization. |
| Inpatients |
● Constant 1:1 observation from the time suicidal thoughts are expressed. ● Follow hospital suicide safety protocols, including room searches for available means for self-harming behavior. ● Urgent psychiatric evaluation. |
Interventions for Reducing Suicide Risk:
Education and Supportive Care: Education can increase awareness about suicide risk factors, reduce stigma and facilitate access to interventions. Ensure that patients are familiar with the National Suicide Prevention Lifeline (1-800-273-TALK (8255)or the Suicide and Crisis Lifeline (988), these resources can be life-saving during a crisis. Supportive care strategies that increase psychosocial support and improve physical and mental well-being can effectively reduce suicide risk by addressing pain, disability, depression, and isolation.
Psychotherapy: Supportive psychotherapy, cognitive behavioral therapy, and dialectical behavioral therapy are evidence-supported interventions that reduce suicide risk, depressive symptoms and psychological distress4. Interventions such as behavioral activation and problem-solving psychotherapy have also been specifically helpful in improving depression and reducing hopelessness and suicide in cancer populations.
Pharmacologic considerations: Treatment of underlying psychiatric and medical disorders is critical to reducing suicide risk. Given the overall complexity of suicidal cancer patients, awareness of the effects of certain medications on existing medical symptoms, adverse effects, and drug-drug interactions is necessary, and we recommend prompt consultation with a psychiatric provider (psychiatrist/ psychiatric advanced practice nurse) when considering instituting a pharmacologic treatment. Specific medication recommendations are beyond the scope of this publication.
Bottom Line:
Suicide rates are higher in patients with cancer compared to the general population. Specific drivers of suicide in cancer patients, such as medical comorbidity, hopelessness, demoralization, existential distress, loss of coping mechanisms, and uncertainty contribute to a more challenging suicide assessment. An institutional strategy that includes standardized screening measures and a low threshold for urgent or emergent psychiatric assessment helps reduce risk among vulnerable patients. A treatment approach that combines medical optimization, psychotherapy, and psychopharmacology optimally relieves suffering and promotes wellness.