Suicide and Desire for Hastened Death in Cancer Settings

Alex Mitchell, Consultant in Psycho-oncology

Leicester General Hospital

LOROS 2011

Introduction

Suicide Statistics in the UK

• Annual number of Suicides in UK 5,000 => 3500• Annual number of Homicides in UK 1,000

• Annual number of Suicides in USA 30,000• Annual number of Homicides in USA 15,000

• Suicide (all ages) is the 8th commonest cause of death• Suicide in adolescents is the 3rd commonest cause of

death

• Annual Suicide rate is 10 per 100,000 population

Suicide EpidemiologyI – By AgeMale Suicide Rate by Age England & Wales 1960-1998

0

50

100

150

200

250

300

350

400

450

1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

Suic

ide

Rate

(per

mill

ion)

65+45-6435-4425-3415-24

Suicide rates previously increased with age, but now are very similar in men and woman across age groups

Antidepressants Prescriptions & Suicide

DSH & Suicide Overview

DSH(150,000)

Suicide(5000)

Depressed

(30%)

Depressed

(80%)

GeneralPop’n

0.01%1%

70%

30%

Depressed

(5%)

In Cancer

Ladder of Suicide Risk

Hopelessness & demoralization

Desire for a hastened death

Suicidal thoughts

Suicidal intent

Suicidal plans

Chochinov – DHD Scale (1995)

• “Do you ever wish that your illness would progress more rapidly so that your suffering could be over sooner?”

• If the patient responds affirmatively ask:

– “Do you wish you were already dead?” – “Do you pray for an early death?”– “Have you discussed with anyone that your desire is to

have an early death?”

Rating the DHD Scale• No information/refusal to answer• No desire to die soon• Slight desire

– has had occasional fleeting thoughts

• Mild desire– often feels that he/she would like to die, but not always)

• Moderate desire– has a genuine desire for death; has discussed this desire with others, but is

not consumed with the prospect)

• Strong desire– has difficulty diverting thoughts from the desire to die; prays for death)

• Extreme desire– obsessed with the wish for death; talks of little else; asks for euthanasia;

prays for death almost constantly)

Rates of DHD

• 44% mild 8% severe in 200 palliative patients

Schedule of Attitudes toward Hastened Death

(1) I feel confident that I will be able to cope with the emotional stress of my illness.(2) I expect to suffer a great deal from emotional problems in the future because of

my illness.(3) My illness has drained me so much that I do not want to go on living.(4) I am seriously considering asking my doctor for help in ending my life.(5) Unless my illness improves I will consider taking steps to end my life.(6) Dying seems like the best way to relieve the pain and discomfort my illness causes.(7) Despite my illness my life still has purpose and meaning.(8) I am careless about my treatment because I want to let the disease run its course.(9) I want to continue living no matter how much pain or suffering my disease causes.(10) I hope my disease will progress rapidly because I would prefer to die rather than

continue living with this illness.

Schedule of Attitudes toward Hastened Death

(11) I have stopped treatment for my illness because I would prefer to let the disease run its course.

(12) I enjoy my present life even with my illness and would not consider ending it.(13) Because my illness cannot be cured I would prefer to die sooner rather than later.(14) Dying seems like the best way to relieve the emotional suffering my illness causes.(15) Doctors will be able to relieve most of the discomfort my illness causes.(16) Because of my illness the idea of dying seems comforting.(17) I expect to suffer a great deal from physical problems in the future because of my illness.(18) I plan to end my own life when my illness becomes too much to bear.(19) I am aggressively pursuing all possible treatments because I'll do anything possible to

continue living.(20) I am able to cope with the symptoms of my illness and have no thoughts of ending my life.

Breitbart et al (2000)

• 92 palliative patients

• 45% endorsed 4 or more items• 17% had high DHD

PHQ9

Leicester Oncology Study – Lord et al

• We analysed data collected from Leicester Cancer Centre from 2008-2009 involving approximately 1000 people approached by a research nurse and two therapeutic radiographers. Of those approached we collected data on 738 presentations, that is people seen up to three times over 9 months during treatment for cancer. We had complete data regarding suicidality on 554 (411 BW 143 BSA). We examined the following factors: treatment intent (radical vs palliative), gender, ethnicity, cancer type, cancer duration.

• We measured suicidal thoughts using the PHQ9, using the scale: not at all 0; several days 1; more than half the days 2; nearly every day 3. We report here, the proportion of people with any suicidal thoughts (non zero scores).

Main Results

• Of 554 patients 44 had some suicidal thoughts (8%)• Of 554 patients 12 had regular suicidal thoughts (2%)

• Of 69 people with major depression, 24 had suicidal thoughts (36.2%)• 95 people had minor depression 7 had suicidal thoughts (7.4%)• 205 people had distress on the DT. 37 had suicidal thoughts (18.0%)

By Ethnicity

• BW• 113 people had major or minor depression. 24 had suicidal thoughts (21.2%)• Of 40 people with major depression, 18 had suicidal thoughts (45%)• 73 people had minor depression 6 had suicidal thoughts (8.2%)• 127 people had distress on the DT. 24 had suicidal thoughts (18.9%)

• BSA• 52 people had major or minor depression. 8 had suicidal thoughts (15.4%)• Of 30 people with major depression, 7 had suicidal thoughts (23.3%)• 23 people had minor depression 1 had suicidal thoughts (4.3%)• 78 people had distress on the DT, 13 had suicidal thoughts (16.6%)

Suicidal thoughts and desire for help

• Of 44 with some suicidal thoughts 30 would consider accepting help (68%)• Of 12 with regular suicidal thoughts only 8 wanted help (67%)• Of 7 with suicidal thoughts nearly every day 5 wanted help (71%)

• Of 24 with suicidal thoughts & major depression, 18 wanted help (75%)• Of 7 people had minor depression & suicidal thought, 4 wanted help (57%)• Of 37 with distress & suicidal thoughts, 29 wanted help

(78.4%)

Predictors 1• THERMOMETERS• depression thermometer b4 = 0.39z = 3.76

• MINI-MAC• helplessness hopelessness b1 = 0.24z = 3.07 p = 0.0021• anxious preoccupation b2 = 0.50z = 4.13 p < 0.0001• Low fighting spirit b3 = -1.06 z = -5.35 p < 0.0001

• HADS• depression total b2 = 0.16z = 2.92 p = 0.0034

• PHQ9• PHQ9 total b1 = 0.58z = 5.41 P < 0.0001•

Predictors 2

• Insurance problems b2 = -2.62 z = -2.10 P = 0.035• Transportation problems b4 = -2.19 z = -2.23 P = 0.025• Partner problems b6 = 1.79 z = 2.18 P = 0.028• Sadness b10 = 2.43 z = 2.62 P = 0.008• Depression b11 = 2.65 z = 3.38 P = 0.000• Self-care problems b20 = 2.72 z = 2.695 P = 0.007• Eating problems b23 = 2.06 z = 2.84 P = 0.004• Diarrhoea b26 = 1.59 z = 2.2 P = 0.026• Urination problems b27 = 1.57 z = 2.27 P = 0.022