This article was downloaded by: [University of Birmingham] On: 29 January 2015, At: 19:44 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Journal of Psychosocial Oncology Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wjpo20
Psychiatric Pathology and Suicide Risk in Patients with Cancer a
b
Anna Costantini PsyD , Maurizio Pompili MD, PhD , Marco Innamorati b
a
a
PsyD , Maria Cristina Zezza PsyD , Alessandra Di Carlo PsyD , Leo c
Sher MD & Paolo Girardi MD
b
a
Psycho-Oncology Unit, Sant’Andrea Hospital, Sapienza University of Rome, Rome, Italy b
Department of Neurosciences, Mental Health and Sensory Functions, Suicide Prevention Center, Sant’Andrea Hospital, Sapienza University of Rome, Rome, Italy c
Click for updates
Mount Sinai School of Medicine and James J. Peters Veterans’ Administration Medical Center, New York, NY, USA Accepted author version posted online: 05 May 2014.Published online: 02 Jul 2014.
To cite this article: Anna Costantini PsyD, Maurizio Pompili MD, PhD, Marco Innamorati PsyD, Maria Cristina Zezza PsyD, Alessandra Di Carlo PsyD, Leo Sher MD & Paolo Girardi MD (2014) Psychiatric Pathology and Suicide Risk in Patients with Cancer, Journal of Psychosocial Oncology, 32:4, 383-395, DOI: 10.1080/07347332.2014.917136 To link to this article: http://dx.doi.org/10.1080/07347332.2014.917136
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &
Downloaded by [University of Birmingham] at 19:44 29 January 2015
Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Journal of Psychosocial Oncology, 32:383–395, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 0734-7332 print / 1540-7586 online DOI: 10.1080/07347332.2014.917136
Psychiatric Pathology and Suicide Risk in Patients with Cancer ANNA COSTANTINI, PsyD Psycho-Oncology Unit, Sant’Andrea Hospital, Sapienza University of Rome, Rome, Italy
Downloaded by [University of Birmingham] at 19:44 29 January 2015
MAURIZIO POMPILI, MD, PhD and MARCO INNAMORATI, PsyD Department of Neurosciences, Mental Health and Sensory Functions, Suicide Prevention Center, Sant’Andrea Hospital, Sapienza University of Rome, Rome, Italy
MARIA CRISTINA ZEZZA, PsyD and ALESSANDRA DI CARLO, PsyD Psycho-Oncology Unit, Sant’Andrea Hospital, Sapienza University of Rome, Rome, Italy
LEO SHER, MD Mount Sinai School of Medicine and James J. Peters Veterans’ Administration Medical Center, New York, NY, USA
PAOLO GIRARDI, MD Department of Neurosciences, Mental Health and Sensory Functions, Suicide Prevention Center, Sant’Andrea Hospital Sapienza University of Rome, Rome, Italy
The aims of the study were to assess sociodemographic and clinical factors associated with suicidal ideation in patients with cancer who required a psycho-oncological support. Among 504 participants, there were 136 (23 men and 113 women) cancer patients who completed psychological assessment when admitted to the Psycho-oncology Outpatient Clinic between 2006 and 2011. Suicidal ideation was assessed by Item 9 of the Brief Symptom Inventory, Hopelessness was assessed by the hopelessness subscale of the Mini-Mental Adjustment to Cancer Scale, and Depression was assessed by the depression subscale of the Hospital and Anxiety Depression Scale. Around 30% of this sample reported affective symptoms and around 20% reported suicidal ideation and hopelessness. Patients who reported suicidal ideation were more hopeless (18.8 ± 6.7 vs. 15.7 ± 5.2; t(134) = 2.54; p < 0.05) and reported more depression (11.8 ± 4.8 vs. 6.8 ± 4.1; t(134) = 5.30; Address correspondence to Maurizio Pompili, MD, PhD, Department of Neurosciences, Mental Health and Sensory Functions, Suicide Prevention Center, Sant’Andrea Hospital, Sapienza University of Rome, Via di Grottarossa 1035 00189, Roma, Italy. E-mail: maurizio. [email protected] 383
384
A. Costantini et al.
p < 0.001). It is evident that cancer can result in a strong psychological distress in the patient. It is important, therefore, that cancer patients receive a proper assistance and psychological support and that both the possible presence of depression and suicidal ideation are constantly monitored. KEYWORDS
psychoncology, cancer, psychiatry, suicide
Downloaded by [University of Birmingham] at 19:44 29 January 2015
INTRODUCTION Many epidemiological studies have shown a high prevalence of major depression and suicide risk among cancer patients with an increased risk of suicide which is approximately 2 to 10 times higher than the general population. Because of the emotional distress among cancer patients due to a diagnosis with possible life-threatening outcome, aggressive medical treatment, and reduced quality of life, scholars worldwide paid increasing attention to screening cancer patients for such conditions. Extensive analyses on developments of screening cancer patients for psychosocial distress are now available (Zabora & Macmurray, 2012). However, the literature still presents inconsistent evidence of the beneficial effects of screening cancer patients for distress pointing to the need of more in-depth knowledge of emotional reactions of such patients (Meijer et al., 2013). Nevertheless, the single-item Distress Thermometer (DT) compared favorably with longer measures currently used to screen for distress to identify patients with a range of problems that were likely to reflect psychological distress. This shows that simple measures may provide necessary indications for proper standards of care (Jacobsen et al., 2005). Several studies demonstrated the role of the location of the tumor: a high rate of depression and suicide risk was found in patients with pancreatic and peritoneum cancer, and in those with esophageal cancer, lung cancer, airway cancer, in the biliary tract and liver cancer (Feigin, 1988). A lower risk, but not entirely absent, was observed in patients with breast cancer, cancer of the uterus, and with myelofibrosis (Bjorkenstam, Edberg, Ayoubi, & Rosen, 2005). As for psychological distress, it was also demonstrated that patients’ conditions depend on neoplasm’s site, suggesting that cancer patients should not be considered as a homogeneous group and, therefore, screening to provide early intervention should be provided. Such approach may provide better quality of life as well as possible improvement in the treatment of cancer (Zabora, BrintzenhofeSzoc, Curbow, Hooker, & Piantadosi, 2001). Other studies showed that the risk of suicide increases during the first year after the diagnosis, therefore the time elapsed between the diagnosis
Downloaded by [University of Birmingham] at 19:44 29 January 2015
Psychiatric Pathology in Cancer
385
and the suicidal act seems to be a highly important factor (Fox, Stanek, Boyd, & Flannery, 1982). The advanced stage and the male gender were indicated as risk factors for suicide too (Hawton, 2000). Many studies have also shown that suicide is more common in individuals with mental disorders comorbidity (Henriksson, Isometsa, Hietanen, Aro, & Lonnqvist, 1995): depression, especially with high levels of hopelessness, and in conjunction with other adverse events that increase the patient stress level. Recently, Mitchell et al. (2011) investigated the prevalence of mood disorders in patients with cancer. These authors conducted meta-analysis and examined the prevalence of mood disorders, anxiety disorders, and adjustment disorder. They concluded that depression and anxiety are less common in patients with cancer than previously reported. However, some combination of mood disorders occurs in 30% to 40% of patients in hospital settings without a significant difference between palliative care and nonpalliative care settings. Therefore, the location of the tumor and the time elapsed since the diagnosis are not the only factors that need to be considered when we talk about the suicide risk. Regarding the comorbidity of depression with cancer, the literature indicates that 15% to 20% of people with cancer show symptoms of depressive disorder (major depression, dysthymia, minor depression) (Clarke, Mackinnon, Smith, McKenzie, & Herrman, 2000; Grassi & Ramelli, 2002). The aim of this study was to explore clinical and sociodemographic variables associated with depression, hopelessness, and suicidal ideation in patients with cancer who required a psycho-oncological support. We hypothesize that suicidal ideation may be associated with the presence of affective symptoms and hopelessness. Furthermore, concordant with the past literature suggesting a link between the presence of physical illness and suicide in older adults we hypothesized that this population will report higher rates of suicidal ideation and despair.
METHOD Patients Participants were 136 (23 men and 113 women) patients with cancer admitted to the Psycho-oncology Outpatient Clinic at Sant’Andrea Hospital in Rome, between 2006 and 2011. Patients who did not complete the psychological assessment (368 altogether) did not differ for clinical and sociodemographic variables compared to patients included in our sample. Reasons for not completing the psychological assessment are diverse, such as patients found hard to answer questions included in the questionnaires or were in painful (psychological and somatic) conditions or simply declined the psychometric evaluation so that psychologists proceeded only with psychopathological
Downloaded by [University of Birmingham] at 19:44 29 January 2015
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A. Costantini et al.
status. Inclusion criteria were a diagnosis of cancer and an age of 18 or older. Exclusion criteria were the presence of conditions affecting the ability to complete the assessment, including refusal to sign the informed consent. Mean age of the participants was 50.95 ± 12.40 years (min./max.: 18/79). Admission to the Psycho-oncology Outpatient Clinic is agreed during hospitalization or during outpatient cancer care. The Psycho-oncology Outpatient Clinic is one of the outpatient clinics of Sant’Andrea Hospital and may also be contacted by citizens as a service provided by the Italian Health System. Reasons for contacting such service vary greatly, but most commonly, patients seek help with regard to mood symptoms. Suicide risk is usually detected during clinical assessment, but sometimes patients report suicidal ideation In 15.4% of patients the cancer was localized in the gastrointestinal system, in 8.8% of patients the diagnosis was lung cancer, in 55.1% the diagnosis was breast cancer, and in 20.6% patients the cancer was localized in other systems. In 62.2% patients the cancer was localized to the site of the primary (original) tumor, in 21.5% it was locoregional, and in 16.3% of the patients it was metastasized. The average time between diagnosis and the assessment was less than one year (0.95 ± 1.94 years; min./max.: 0/13 years). The variables examined were the gender, the cancer location and its stage, the elapsed time from diagnosis, and other sociodemographic variables; the correlation between the malignancy presence and cancer medical treatment, the suicidal ideation (assessed by Brief Symptom Inventory [BSI] Item 9), the Hopelessness (assessed by MINI-Mental Adjustment to Cancer Scale [MINIMAC], Hopelessness subscale) and the presence of Depression (assessed by the Hospital and Anxiety Depression Scale [HADS], Depression subscale) was also investigated. Patients participated voluntarily in the study, and each patient provided the written informed consent. The study protocol received ethics approval from the local research ethics review board.
Measures All the patients completed the assessment in the first 3 days since admission to the Department. The patients were administered the HADS, Item 9 of the BSI, and the MINIMAC Hopelessness. The HADS (Zigmond & Snaith, 1983) is a self-report rating scale of 14 items to assess anxiety and depression specifically developed for the evaluation of these parameters in medical patients and its use in oncology is the gold standard method. The HADS was developed by Zigmond in 1983 to provide clinicians and researchers with a valuable and practical tool to identify and quantify the two most frequent psychopathological disorders in medical patients: depression and anxiety (Zigmond & Snaith, 1983). It was designed with particular attention to some specific
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Psychiatric Pathology in Cancer
387
issues especially relevant in somatic medicine. The scale is composed by 14 items, on a 4-point scale (0–3), which makes it easy to administer, and well accepted. Severe psychopathological symptoms are not covered. This is thought to improve acceptability and make the scale more sensitive to mild forms of psychiatric disorders, thus avoiding the “floor effect,” which is frequently observed when psychiatric questionnaires are used with medical patients. In this study only the items on the Depression subscale were considered. The BSI (Derogatis & Melisaratos, 1983) is a self-report questionnaire of 53 items, rated on a 5-point Likert-type scale, constructed to assess psychopathological symptoms in patients with medical or psychiatric pathology. The BSI is the short form of the Symptom Checklist-90-R (SCL-90; Derogatis, 1977), a self-report questionnaire that explores nine main psychopathological dimensions: somatization, obsessive compulsive traits, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism. For the purposes of our research, for the suicidal ideation assessment the Item 9 of this instrument (“ideas of suicide”) was considered. Patients had to answer indicating the frequency on a 5-point scale: nothing, a little, enough, much, very much. The MINIMAC Hopelessness (Watson et al., 1994) is the short form of the “Mental Adjustment to Cancer” by Watson. It is a tool made up of 29 items, assessed on a 4-point Likert-type scale, aimed at investigating the main styles of coping with cancer: fighting spirit (the tendency to fight the disease and consider it an existential challenge), hopelessness-helplessness (tendency to adopt a pessimistic attitude toward the disease), fatalism (resigned and stoic tendency to perceive the illness), anxious preoccupation (tendency to perception of symptoms experienced in terms of illness), denial-avoidance (tendency to use defensive mechanism not to think about the disease). To assess the presence of desperation and hopelessness, in this study we considered only the items constituting the Hopelessness-Helplessness factor: Item 4 “I want to drop everything,” Item 6 “I feel completely lost on what to do,” Item 12 “I cannot control the situation,” Item 14 “I do not have much hope for the future,” Item 15 “I feel that there is nothing I can do to help,” Item 16 “I think that the world is falling apart on me,” Item 20 “I feel that life is hopeless,” Item 21” I cannot cope with the situation.”
Statistical Analysis t Tests for dimensional variables and chi-squared tests (χ 2 tests) for NxN contingency tables or one-way Fisher exact tests for 2 × 2 contingency tables were used to assess bivariate differences between groups. Variables significant at the bivariate analyses were entered in a multinomial regression analysis as independent variables. Groups of patients with suicidal ideation
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versus patients without suicidal ideation were entered as dependent variable. Associations were reported as odds ratio (OR). All the analyses were performed with the statistical package for the social sciences SPSS for Windows 19.0.
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RESULTS Around 18% of the patients reported they had suicidal ideation, at least sometimes. Around 29% of the patients had a score of 11 or higher on the HADS Depression (mean score for the whole sample: 7.74 ± 4.61), and 25.7% had a score of 20.59 or higher on the MINIMAC Hopelessness (mean score for the whole sample: 16.23 ± 5.63). Older adults tended to report suicidal ideation more frequently (25% vs. 17%; p < 0.28) and MINIMAC scores of 20.59 or higher (40% vs. 21%; p < 0.07) compared to younger patients, despite the fact that they reported almost the same number of depressive symptoms (7.90 ± 4.45 vs. 7.65 ± 4.68; t(134) = .82; p = .82). Furthermore, when assessing the linear association between age and scores on the HADS Depression, the coefficient of correlation was weak and not significant (r = .14; p = .12; not reported in the tables), indicating that in this sample depressive symptoms severity was not associated with age of the patients. These results were replicated also when considering only cognitive components of depression (r coefficient of correlation was 0.08 [p = .39] for the association between age and the MINIMAC Hopelessness). Patients who reported suicidal ideation differed from those who did not report suicidal ideation for some clinical and sociodemographic variables (see Table 1). Patients with suicidal ideation were older (56.46 ± 10.24 vs. 49.73 ± 12.55; t(134) = 2.45; p < 0.05), and they were less frequently treated with chemotherapy (42.9% vs. 66.7%; p < 0.05) than patients without suicidal ideation. Moreover, they had higher mean scores on the MINIMAC Hopelessness (18.76 ± 6.73 vs. 15.66 ± 5.22; t(134) = 2.54; p < 0.05), and higher mean scores on the HADS Depression (11.76 ± 4.75 vs. 6.83 ± 4.08; t(134) = 5.30; p < 0.001) than patients without suicidal ideation. Sixty percent of the patients with suicidal ideation had scores of 11 or higher on the HADS Depression, and 48% had scores of 20.59 on the MINIMAC Hopelessness. The groups did not differ for localization of the primary tumor and staging of the cancer. The most common cancer was the breast cancer (48.0% and 56.8%, respectively, for patients with and without suicidal ideation); χ 2(3) = 4.86; p = .18). Above 60% of the patients with and without suicidal ideation had a cancer localized to the site of the primary tumor (χ 2(2) = .70; p = .70), and the time between diagnosis and the psychological assessment was less than 1 year (0.77 ± 1.23 and 0.99 ± 2.06, respectively, for patients with suicidal ideation and those without suicidal ideation; t(134) = –0.48; p = .64).
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Psychiatric Pathology in Cancer TABLE 1 Differences Between Groups
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Patients without Patients with Suicidal Ideation Suicidal Ideation (n = 111) (n = 25) Men Age - M ± SD Live alone Marital status Single Married Divorced or widowed Retired School: 8 years or fewer Localization of the primary tumor Lungs Gastrointestinal Breast Other Staging Localized Locoregional Metastatic Chemotherapy Surgery Radiotherapy Hormone therapy Years since the diagnosis - M ± SD MINIMAC Hopelessness - M ± SD MINIMAC Hopelessness ≥ 20.59 HADS - M ± SD HADS ≥ 11
16.2% 49.73 ± 12.55 11.4%
20.0% 56.46 ± 10.24 12.5%
12.4% 66.7% 21.0% 17.9% 23.1%
8.3% 75.0% 16.7% 20.8% 25.0%
6.3% 16.2% 56.8% 20.7%
20.0% 12.0% 48.0% 20.0%
61.8% 22.7% 15.5% 66.7% 43.8% 37.1% 8.6% 0.99 ± 2.06 15.66 ± 5.22 20.7% 6.83 ± 4.08 21.6%
64.0% 16.0% 20.0% 42.9% 38.1% 33.3% 19.0% 0.77 ± 1.23 18.76 ± 6.73 48.0% 11.76 ± 4.75 60.0%
Test
p
Journal of Psychosocial Oncology Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wjpo20
Psychiatric Pathology and Suicide Risk in Patients with Cancer a
b
Anna Costantini PsyD , Maurizio Pompili MD, PhD , Marco Innamorati b
a
a
PsyD , Maria Cristina Zezza PsyD , Alessandra Di Carlo PsyD , Leo c
Sher MD & Paolo Girardi MD
b
a
Psycho-Oncology Unit, Sant’Andrea Hospital, Sapienza University of Rome, Rome, Italy b
Department of Neurosciences, Mental Health and Sensory Functions, Suicide Prevention Center, Sant’Andrea Hospital, Sapienza University of Rome, Rome, Italy c
Click for updates
Mount Sinai School of Medicine and James J. Peters Veterans’ Administration Medical Center, New York, NY, USA Accepted author version posted online: 05 May 2014.Published online: 02 Jul 2014.
To cite this article: Anna Costantini PsyD, Maurizio Pompili MD, PhD, Marco Innamorati PsyD, Maria Cristina Zezza PsyD, Alessandra Di Carlo PsyD, Leo Sher MD & Paolo Girardi MD (2014) Psychiatric Pathology and Suicide Risk in Patients with Cancer, Journal of Psychosocial Oncology, 32:4, 383-395, DOI: 10.1080/07347332.2014.917136 To link to this article: http://dx.doi.org/10.1080/07347332.2014.917136
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &
Downloaded by [University of Birmingham] at 19:44 29 January 2015
Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Journal of Psychosocial Oncology, 32:383–395, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 0734-7332 print / 1540-7586 online DOI: 10.1080/07347332.2014.917136
Psychiatric Pathology and Suicide Risk in Patients with Cancer ANNA COSTANTINI, PsyD Psycho-Oncology Unit, Sant’Andrea Hospital, Sapienza University of Rome, Rome, Italy
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MAURIZIO POMPILI, MD, PhD and MARCO INNAMORATI, PsyD Department of Neurosciences, Mental Health and Sensory Functions, Suicide Prevention Center, Sant’Andrea Hospital, Sapienza University of Rome, Rome, Italy
MARIA CRISTINA ZEZZA, PsyD and ALESSANDRA DI CARLO, PsyD Psycho-Oncology Unit, Sant’Andrea Hospital, Sapienza University of Rome, Rome, Italy
LEO SHER, MD Mount Sinai School of Medicine and James J. Peters Veterans’ Administration Medical Center, New York, NY, USA
PAOLO GIRARDI, MD Department of Neurosciences, Mental Health and Sensory Functions, Suicide Prevention Center, Sant’Andrea Hospital Sapienza University of Rome, Rome, Italy
The aims of the study were to assess sociodemographic and clinical factors associated with suicidal ideation in patients with cancer who required a psycho-oncological support. Among 504 participants, there were 136 (23 men and 113 women) cancer patients who completed psychological assessment when admitted to the Psycho-oncology Outpatient Clinic between 2006 and 2011. Suicidal ideation was assessed by Item 9 of the Brief Symptom Inventory, Hopelessness was assessed by the hopelessness subscale of the Mini-Mental Adjustment to Cancer Scale, and Depression was assessed by the depression subscale of the Hospital and Anxiety Depression Scale. Around 30% of this sample reported affective symptoms and around 20% reported suicidal ideation and hopelessness. Patients who reported suicidal ideation were more hopeless (18.8 ± 6.7 vs. 15.7 ± 5.2; t(134) = 2.54; p < 0.05) and reported more depression (11.8 ± 4.8 vs. 6.8 ± 4.1; t(134) = 5.30; Address correspondence to Maurizio Pompili, MD, PhD, Department of Neurosciences, Mental Health and Sensory Functions, Suicide Prevention Center, Sant’Andrea Hospital, Sapienza University of Rome, Via di Grottarossa 1035 00189, Roma, Italy. E-mail: maurizio. [email protected] 383
384
A. Costantini et al.
p < 0.001). It is evident that cancer can result in a strong psychological distress in the patient. It is important, therefore, that cancer patients receive a proper assistance and psychological support and that both the possible presence of depression and suicidal ideation are constantly monitored. KEYWORDS
psychoncology, cancer, psychiatry, suicide
Downloaded by [University of Birmingham] at 19:44 29 January 2015
INTRODUCTION Many epidemiological studies have shown a high prevalence of major depression and suicide risk among cancer patients with an increased risk of suicide which is approximately 2 to 10 times higher than the general population. Because of the emotional distress among cancer patients due to a diagnosis with possible life-threatening outcome, aggressive medical treatment, and reduced quality of life, scholars worldwide paid increasing attention to screening cancer patients for such conditions. Extensive analyses on developments of screening cancer patients for psychosocial distress are now available (Zabora & Macmurray, 2012). However, the literature still presents inconsistent evidence of the beneficial effects of screening cancer patients for distress pointing to the need of more in-depth knowledge of emotional reactions of such patients (Meijer et al., 2013). Nevertheless, the single-item Distress Thermometer (DT) compared favorably with longer measures currently used to screen for distress to identify patients with a range of problems that were likely to reflect psychological distress. This shows that simple measures may provide necessary indications for proper standards of care (Jacobsen et al., 2005). Several studies demonstrated the role of the location of the tumor: a high rate of depression and suicide risk was found in patients with pancreatic and peritoneum cancer, and in those with esophageal cancer, lung cancer, airway cancer, in the biliary tract and liver cancer (Feigin, 1988). A lower risk, but not entirely absent, was observed in patients with breast cancer, cancer of the uterus, and with myelofibrosis (Bjorkenstam, Edberg, Ayoubi, & Rosen, 2005). As for psychological distress, it was also demonstrated that patients’ conditions depend on neoplasm’s site, suggesting that cancer patients should not be considered as a homogeneous group and, therefore, screening to provide early intervention should be provided. Such approach may provide better quality of life as well as possible improvement in the treatment of cancer (Zabora, BrintzenhofeSzoc, Curbow, Hooker, & Piantadosi, 2001). Other studies showed that the risk of suicide increases during the first year after the diagnosis, therefore the time elapsed between the diagnosis
Downloaded by [University of Birmingham] at 19:44 29 January 2015
Psychiatric Pathology in Cancer
385
and the suicidal act seems to be a highly important factor (Fox, Stanek, Boyd, & Flannery, 1982). The advanced stage and the male gender were indicated as risk factors for suicide too (Hawton, 2000). Many studies have also shown that suicide is more common in individuals with mental disorders comorbidity (Henriksson, Isometsa, Hietanen, Aro, & Lonnqvist, 1995): depression, especially with high levels of hopelessness, and in conjunction with other adverse events that increase the patient stress level. Recently, Mitchell et al. (2011) investigated the prevalence of mood disorders in patients with cancer. These authors conducted meta-analysis and examined the prevalence of mood disorders, anxiety disorders, and adjustment disorder. They concluded that depression and anxiety are less common in patients with cancer than previously reported. However, some combination of mood disorders occurs in 30% to 40% of patients in hospital settings without a significant difference between palliative care and nonpalliative care settings. Therefore, the location of the tumor and the time elapsed since the diagnosis are not the only factors that need to be considered when we talk about the suicide risk. Regarding the comorbidity of depression with cancer, the literature indicates that 15% to 20% of people with cancer show symptoms of depressive disorder (major depression, dysthymia, minor depression) (Clarke, Mackinnon, Smith, McKenzie, & Herrman, 2000; Grassi & Ramelli, 2002). The aim of this study was to explore clinical and sociodemographic variables associated with depression, hopelessness, and suicidal ideation in patients with cancer who required a psycho-oncological support. We hypothesize that suicidal ideation may be associated with the presence of affective symptoms and hopelessness. Furthermore, concordant with the past literature suggesting a link between the presence of physical illness and suicide in older adults we hypothesized that this population will report higher rates of suicidal ideation and despair.
METHOD Patients Participants were 136 (23 men and 113 women) patients with cancer admitted to the Psycho-oncology Outpatient Clinic at Sant’Andrea Hospital in Rome, between 2006 and 2011. Patients who did not complete the psychological assessment (368 altogether) did not differ for clinical and sociodemographic variables compared to patients included in our sample. Reasons for not completing the psychological assessment are diverse, such as patients found hard to answer questions included in the questionnaires or were in painful (psychological and somatic) conditions or simply declined the psychometric evaluation so that psychologists proceeded only with psychopathological
Downloaded by [University of Birmingham] at 19:44 29 January 2015
386
A. Costantini et al.
status. Inclusion criteria were a diagnosis of cancer and an age of 18 or older. Exclusion criteria were the presence of conditions affecting the ability to complete the assessment, including refusal to sign the informed consent. Mean age of the participants was 50.95 ± 12.40 years (min./max.: 18/79). Admission to the Psycho-oncology Outpatient Clinic is agreed during hospitalization or during outpatient cancer care. The Psycho-oncology Outpatient Clinic is one of the outpatient clinics of Sant’Andrea Hospital and may also be contacted by citizens as a service provided by the Italian Health System. Reasons for contacting such service vary greatly, but most commonly, patients seek help with regard to mood symptoms. Suicide risk is usually detected during clinical assessment, but sometimes patients report suicidal ideation In 15.4% of patients the cancer was localized in the gastrointestinal system, in 8.8% of patients the diagnosis was lung cancer, in 55.1% the diagnosis was breast cancer, and in 20.6% patients the cancer was localized in other systems. In 62.2% patients the cancer was localized to the site of the primary (original) tumor, in 21.5% it was locoregional, and in 16.3% of the patients it was metastasized. The average time between diagnosis and the assessment was less than one year (0.95 ± 1.94 years; min./max.: 0/13 years). The variables examined were the gender, the cancer location and its stage, the elapsed time from diagnosis, and other sociodemographic variables; the correlation between the malignancy presence and cancer medical treatment, the suicidal ideation (assessed by Brief Symptom Inventory [BSI] Item 9), the Hopelessness (assessed by MINI-Mental Adjustment to Cancer Scale [MINIMAC], Hopelessness subscale) and the presence of Depression (assessed by the Hospital and Anxiety Depression Scale [HADS], Depression subscale) was also investigated. Patients participated voluntarily in the study, and each patient provided the written informed consent. The study protocol received ethics approval from the local research ethics review board.
Measures All the patients completed the assessment in the first 3 days since admission to the Department. The patients were administered the HADS, Item 9 of the BSI, and the MINIMAC Hopelessness. The HADS (Zigmond & Snaith, 1983) is a self-report rating scale of 14 items to assess anxiety and depression specifically developed for the evaluation of these parameters in medical patients and its use in oncology is the gold standard method. The HADS was developed by Zigmond in 1983 to provide clinicians and researchers with a valuable and practical tool to identify and quantify the two most frequent psychopathological disorders in medical patients: depression and anxiety (Zigmond & Snaith, 1983). It was designed with particular attention to some specific
Downloaded by [University of Birmingham] at 19:44 29 January 2015
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issues especially relevant in somatic medicine. The scale is composed by 14 items, on a 4-point scale (0–3), which makes it easy to administer, and well accepted. Severe psychopathological symptoms are not covered. This is thought to improve acceptability and make the scale more sensitive to mild forms of psychiatric disorders, thus avoiding the “floor effect,” which is frequently observed when psychiatric questionnaires are used with medical patients. In this study only the items on the Depression subscale were considered. The BSI (Derogatis & Melisaratos, 1983) is a self-report questionnaire of 53 items, rated on a 5-point Likert-type scale, constructed to assess psychopathological symptoms in patients with medical or psychiatric pathology. The BSI is the short form of the Symptom Checklist-90-R (SCL-90; Derogatis, 1977), a self-report questionnaire that explores nine main psychopathological dimensions: somatization, obsessive compulsive traits, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism. For the purposes of our research, for the suicidal ideation assessment the Item 9 of this instrument (“ideas of suicide”) was considered. Patients had to answer indicating the frequency on a 5-point scale: nothing, a little, enough, much, very much. The MINIMAC Hopelessness (Watson et al., 1994) is the short form of the “Mental Adjustment to Cancer” by Watson. It is a tool made up of 29 items, assessed on a 4-point Likert-type scale, aimed at investigating the main styles of coping with cancer: fighting spirit (the tendency to fight the disease and consider it an existential challenge), hopelessness-helplessness (tendency to adopt a pessimistic attitude toward the disease), fatalism (resigned and stoic tendency to perceive the illness), anxious preoccupation (tendency to perception of symptoms experienced in terms of illness), denial-avoidance (tendency to use defensive mechanism not to think about the disease). To assess the presence of desperation and hopelessness, in this study we considered only the items constituting the Hopelessness-Helplessness factor: Item 4 “I want to drop everything,” Item 6 “I feel completely lost on what to do,” Item 12 “I cannot control the situation,” Item 14 “I do not have much hope for the future,” Item 15 “I feel that there is nothing I can do to help,” Item 16 “I think that the world is falling apart on me,” Item 20 “I feel that life is hopeless,” Item 21” I cannot cope with the situation.”
Statistical Analysis t Tests for dimensional variables and chi-squared tests (χ 2 tests) for NxN contingency tables or one-way Fisher exact tests for 2 × 2 contingency tables were used to assess bivariate differences between groups. Variables significant at the bivariate analyses were entered in a multinomial regression analysis as independent variables. Groups of patients with suicidal ideation
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versus patients without suicidal ideation were entered as dependent variable. Associations were reported as odds ratio (OR). All the analyses were performed with the statistical package for the social sciences SPSS for Windows 19.0.
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RESULTS Around 18% of the patients reported they had suicidal ideation, at least sometimes. Around 29% of the patients had a score of 11 or higher on the HADS Depression (mean score for the whole sample: 7.74 ± 4.61), and 25.7% had a score of 20.59 or higher on the MINIMAC Hopelessness (mean score for the whole sample: 16.23 ± 5.63). Older adults tended to report suicidal ideation more frequently (25% vs. 17%; p < 0.28) and MINIMAC scores of 20.59 or higher (40% vs. 21%; p < 0.07) compared to younger patients, despite the fact that they reported almost the same number of depressive symptoms (7.90 ± 4.45 vs. 7.65 ± 4.68; t(134) = .82; p = .82). Furthermore, when assessing the linear association between age and scores on the HADS Depression, the coefficient of correlation was weak and not significant (r = .14; p = .12; not reported in the tables), indicating that in this sample depressive symptoms severity was not associated with age of the patients. These results were replicated also when considering only cognitive components of depression (r coefficient of correlation was 0.08 [p = .39] for the association between age and the MINIMAC Hopelessness). Patients who reported suicidal ideation differed from those who did not report suicidal ideation for some clinical and sociodemographic variables (see Table 1). Patients with suicidal ideation were older (56.46 ± 10.24 vs. 49.73 ± 12.55; t(134) = 2.45; p < 0.05), and they were less frequently treated with chemotherapy (42.9% vs. 66.7%; p < 0.05) than patients without suicidal ideation. Moreover, they had higher mean scores on the MINIMAC Hopelessness (18.76 ± 6.73 vs. 15.66 ± 5.22; t(134) = 2.54; p < 0.05), and higher mean scores on the HADS Depression (11.76 ± 4.75 vs. 6.83 ± 4.08; t(134) = 5.30; p < 0.001) than patients without suicidal ideation. Sixty percent of the patients with suicidal ideation had scores of 11 or higher on the HADS Depression, and 48% had scores of 20.59 on the MINIMAC Hopelessness. The groups did not differ for localization of the primary tumor and staging of the cancer. The most common cancer was the breast cancer (48.0% and 56.8%, respectively, for patients with and without suicidal ideation); χ 2(3) = 4.86; p = .18). Above 60% of the patients with and without suicidal ideation had a cancer localized to the site of the primary tumor (χ 2(2) = .70; p = .70), and the time between diagnosis and the psychological assessment was less than 1 year (0.77 ± 1.23 and 0.99 ± 2.06, respectively, for patients with suicidal ideation and those without suicidal ideation; t(134) = –0.48; p = .64).
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Psychiatric Pathology in Cancer TABLE 1 Differences Between Groups
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Patients without Patients with Suicidal Ideation Suicidal Ideation (n = 111) (n = 25) Men Age - M ± SD Live alone Marital status Single Married Divorced or widowed Retired School: 8 years or fewer Localization of the primary tumor Lungs Gastrointestinal Breast Other Staging Localized Locoregional Metastatic Chemotherapy Surgery Radiotherapy Hormone therapy Years since the diagnosis - M ± SD MINIMAC Hopelessness - M ± SD MINIMAC Hopelessness ≥ 20.59 HADS - M ± SD HADS ≥ 11
16.2% 49.73 ± 12.55 11.4%
20.0% 56.46 ± 10.24 12.5%
12.4% 66.7% 21.0% 17.9% 23.1%
8.3% 75.0% 16.7% 20.8% 25.0%
6.3% 16.2% 56.8% 20.7%
20.0% 12.0% 48.0% 20.0%
61.8% 22.7% 15.5% 66.7% 43.8% 37.1% 8.6% 0.99 ± 2.06 15.66 ± 5.22 20.7% 6.83 ± 4.08 21.6%
64.0% 16.0% 20.0% 42.9% 38.1% 33.3% 19.0% 0.77 ± 1.23 18.76 ± 6.73 48.0% 11.76 ± 4.75 60.0%
Test
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