SUICIDE RISK IN PALLIATIVE/ EoL SETTINGS

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1 SUICIDE RISK IN PALLIATIVE/ EoL SETTINGS M A R C K I N G S L S E Y C. P S Y C H O L C O N S U L T A N T C L I N I C A L P S Y C H O L O G I S T / P S Y C H O -ON C O L O GI S T SUICIDE RISK IN PALLIATIVE/ EoL SETTINGS Emotional challenges characterize living with chronic or life limiting illness/ death and dying Loss and grief often experienced : patients lose health, function, independence, autonomy, control, predictability, and mental clarity, as well as future hopes and dreams Some may lose status in family and/or a sense of belonging These reactions may accompany a waning will to live and a growing desire for death (Chochinov et al., 2002) RESPONSES TO ILLNESS Discriminate between normal and pathological responses to life-limiting illness. For example, psychologists may be asked to distinguish the common desire for suffering to end (without a specific plan to end suffering) from suicidal ideation and associated requests for hastened death Psychologists often find themselves needing to sit with and validate individuals suffering while raising the possibility that life still can have meaning in the midst of suffering SUICIDE RISK IN PALLIATIVE CARE Suicidal thoughts are common in terminally ill patients but are usually fleeting The desire to hasten death in not necessarily synonymous with a request to hasten death Multiple vulnerability factors present simultaneously in patients. However, the loss of control and autonomy and of being a burden on others were the most relevant. Fear of uncontrolled pain Loss of Dignity very significant risk factor Suicide in Palliative Care Advanced Cancer At least 10% of suicides in Britain are linked to terminal or chronic illness Suicide among terminally and chronically ill people is much more prevalent, and a much greater problem than public policy currently recognises. Limited studies and poor national reporting of suicide in advanced physical illness Wide variation in coroners reporting on advanced illness as a background factor in suicide People with advanced illness considered a high risk group for suicide and greater attention should be given to providing better psychological support to this group. Compared with the general population, patients with cancer have a 60% higher suicide rate (2017 data) Time since diagnosis as a critical factor: 40% of cancer deaths due to suicide occurred in the first year after diagnosis. Risk is highest in the first three months post-diagnosis A large study in Sweden found that the relative risk of suicide was almost 13 times higher than those without cancer during the first week after diagnosis, dropping to 3.3 times more likely during the first year.. 1

2 Demographics Demographics Age - People with cancer over the age of 65 are more likely to take their lives than those under age 65. Suicide rates are the highest in men over the age of 80. An exception is that women with ovarian cancer are more at risk if they are younger than older. Sex - Men with cancer are more likely to commit suicide than women with cancer. Poor prognosis - People who have a cancer that carries a poor prognosis are more likely to consider suicide Metastatic disease is associated with a higher risk of suicide. Inability to Work - Suicidal thoughts were six times more common in people who were unable to perform the duties required by their job Type of Cancer and suicide risk Advanced Cancer Male patients with pancreatic cancer had a suicide risk 11 times that of the general population. Lung Cancer diagnosis raised the odds of suicide by over four times compared to people in the general population (2017 study). Lung: least amount of time between diagnosis and suicide a median of 7 months Lung: more likely to die by suicide if they were male, widowed, older (70-75 years), refused surgical treatment or had a difficult-to-treat type of cancer (metastatic, small-cell lung carcinoma histology). Suicide in head and neck cancer was increased if surgery was contraindicated. Breast cancer patients had elevated levels of risk compared to cancers with a similarly good prognosis Delirium and other cognitive disorders place terminally ill patients at risk for suicidality by impairing impulse control and judgement. Pain: patients with severe pain, which was often inadequately controlled and poorly tolerated. Fear of Loss of control of physical/mental abilities DEPRESSION AND HOPLESSNESS The wish to die in any individual will inevitably be influenced by a number of different factors in their life Depression is a factor in at least 50% of all advanced care suicides 36 per cent -60 per cent of multiple sclerosis patients will suffer from major depression at some point Fear of/ reported loss of control in MS as precipitating suicidal thoughts. Hopelessness, rather than depression used in the literature to describe the relationship between motor neurone disease and suicidal ideation. HOPELESSNESS Patients must cope with increasing physical limitations as well as the emotional impact of their illness and, in particular, the poor prognosis. In the context of these stressors, some patients appear to be overwhelmed by feelings of hopelessness or despair. Hopelessness is a potent predictor of suicidal intent, not only shorter -term, but over a longer period of time. Hopelessness more highly correlated with suicidal ideation in terminally ill patients compared to level of depression 2

3 HOPELESSNESS: 4 KEY ITEMS DEMORALISATION Item 6: In the future I expect to succeed in what concerns me most. Item 7: My future seems dark to me. Item 9: I just don't get the breaks and there is no reason to believe I will in the future. Item 15: I have great faith in the future. Hopelessness is the hallmark of demoralisation Demoralisation is a significant factor in the psychological distress experienced by advanced medically ill patients The dictionary meaning of demoralise is to deprive a person of spirit, courage, to dishearten, bewilder, to throw a person into disorder or confusion DEMORALISATION 2 Emotional phases in clinical studies: Initial Phase: a range of emotions ( such as ) Anger, resentment, sadness, anxiety, puzzlement, discouragement and a frustrating sense of incompetence are the main emotions characterising demoralisation in its initial stage Later Phase: acceptance of fate, inaction and impasse, the giving-up given-up complex. Acceptance of the (adverse) situation, Giving up of hope Giving up on the desire to change Individuals may report relationship strain or tension related to treatment demands and associated symptom and caregiver burden or longstanding family dynamics. They may feel reduced by the disease and robbed of any sense of purpose, meaning, or even personhood. Importance of psychotherapy address dignity, meaning and purpose Address relationship distress in context of advanced illness. The meaning of life always changes, but... it never ceases to be... we can discover this meaning in life in three different ways: (1) by creating a work or doing a deed; (2) by experiencing something or encountering someone; and (3) by the attitude we take toward unavoidable suffering. Viktor E. Frankl, Man s Search for Meaning Struggle with issues of identity, value, purpose, meaning, and faith These reactions may accompany a waning will to live and hasten death We also need to be mindful of the positive emotions and sense of well-being that individuals can experience in advanced stages Result in expressions of gratitude, compassion, forgiveness, spiritual comfort, and posttraumatic growth. Hope for meaningful experiences at end of life 3

4 INTERPERSONAL THEORY OF SUICIDE: JOINER 2005 Thwarted Belongingness 3 simultaneous components: THWARTED BELONGINGNES PERCEIVED BURDEONSOMNESS DESIRE FOR SUICIDE ACQUIRED CAPABILITY Belongingness feeling accepted by others is a essential for an individual's psychological health and well-being Increased social connectedness-a construct related to belongingness has been shown to lower risk for suicide More specifically, being married, having children, and having more friends are associated with a lower risk of suicidal behaviour. Social isolation: unmet need to belong (Baumeister) Perceived Burdensomeness SOCIAL IMPACT Perceived burdensomeness is the belief that one is a burden on others or society. Joiner (2005) describes perceived burdensomeness as the belief that "my death is worth more than my life Burdensomeness may be "perceived", and is often a false belief (linked to depression-negative cognitions) Psychologically-painful mental states-increase despair and defeat Poor communication may become a risk within and across all levels of the patient s medical and psychosocial system as medical options for a cure are exhausted Patients may worry about how their illness affects family members Increased dependency and loss of autonomy may result in perceived feelings of failure, social ineptness (Chuek, 2005) Individuals may experience depression associated with a diminished sense dignity EVIDENCE-BASED APPROACHES MBT: Meaning Based Therapy (Individual and Group): 8 structured manualised sessions (Breitbart, 2015) Dignity Therapy (Chochinov, 2012): Value based approach linked with interpersonal aspects of treatment ACT ( Acceptance and Commitment Therapy) CBT/ BCT PSYCHODYNAMIC THERAPY MYTH: You have to be mentally ill to even think about suicide. FACT: Most people have thought of suicide from time to time and not all people who die by suicide have diagnosed mental illness the time of death. MYTH: People who talk about suicide aren t really serious and not likely to actually kill themselves. FACT: People who kill themselves have often told someone that they do not feel life is worth living or that they have no future. Some may have actually said they want to die. it is very important that everyone who says they feel suicidal be treated seriously. 4

5 MYTH: Once a person has made a serious suicide attempt, that person is unlikely to make another. FACT: People who have attempted to kill themselves are significantly more likely to eventually die by suicide than the rest of the population. MYTH: If a person is serious about killing themselves then there is nothing you can do. FACT: Feeling suicidal is often a temporary state of mind. Whilst someone may feel low or distressed for a sustained period the actual suicidal crisis can be relatively short term. This is what makes timely emotional support so important. MYTH: Talking about suicide is a bad idea as it may give someone the idea to try it. FACT: People who have been through such a crisis will often say that it was a huge relief to be able to talk about their suicidal thoughts. Greater chance of discovering other options to suicide. MYTH: Most suicides happen in the winter months. FACT: Suicide is more common in the spring and summer months. Depression and Cancer MYTH: People who threaten suicide are just attention seeking and shouldn t be taken seriously. FACT: People may well talk about their feelings because they want support in dealing with them. In this sense it may be that they do indeed want attention in which case giving that attention may save their life. MYTH: People who are suicidal want to die. FACT: The majority of people who feel suicidal do not actually want to die; they do not want to live the life they have. The distinction may seem small but is in fact very important and is why talking through other options at the right time is so vital % cancer patients meet criteria for clinical depression (Croyle & Rowland, 2003) People with cancer about 4 times as likely to develop clinical depression compared to general population (Spiegel & Giese-Davis, 2003) Depression reduces the QoL of cancer patients No evidence to suggest that depression is linked to actual cause of cancer Factors increasing risk for depression in cancer patients Cancer patients with more severe physical disabilities and higher cancer staging at increased risk of developing depression Greater limitations in physical abilities in +65 yrs (Croyle & Rowland, 2003) Location of cancer pancreatic, liver. Lung, leukaemia most vulnerable (Zabora et al., 01) Metastatic cancer Chemotherapy drugs (L-asparaginase vinblastine), interferon medications, steroid agents (e.g. prednisone) increase risk of depression 5