Factors Associated with Suicidal Ideation, and Attempt Among Cancer Patients in Ayder Comprehensive Specialized Hospital: Cross-Sectional, Mekelle, Ethiopia

1. INTRODUCTION

Suicide means the act of a person intentionally causing his or her death. A suicide attempt is a known habitual act with the nonfatal outcome that is deliberately initiated and performed by the individual [1,2]. Cancer is a disease with abnormal cells growth, reproducing uncontrollably and invading nearby tissue by spreading to other parts of the body through bloodstreams and lymphatic systems. Worldwide, about 25 million people are living with cancer. Each year, 7 million people die from it. The World Health Organization (WHO) estimated in 2011 that 34% of the Ethiopian population is dying from a non-communicable disease, with a cancer prevalence of 40%[3-6].

Cancer patients are at high risk for suicide, particularly when they are informed about the cancer diagnosis or hospitalized for cancer treatment [7]. The risk of attempted and completed suicide among cancer patients is much higher than the general population [8,9]. Various studies have reported that the diagnosis of cancer is two to five times the risk factor for suicide when compared to the general population [5,6,9,10], with 8.5% to 26% of terminal cancer patients have a higher level of the “desire for hastened death [11].

A study conducted in the United Kingdom showed that 7.8% of cancer outpatients have suicidal ideation [12], while 10.9% of breast cancer patients undergoing surgery in Korea [9], and 8.6% of terminal cancer outpatients in Japan [13] have suicidal ideation, with its variation, ranging from 0.8 to 71% in non-psychiatric populations of cancer patients compared to 1.1 and 19.8% suicidal ideation in the general population [14].

The finding of this study shows that 15.3% cancer inpatients of Chinese general hospitals in the Tianjin area reported having suicidal ideation the previous month [7]. The prevalence found in Chinese cancer inpatients is similar to that reported in other cohorts, including the 17.7% prevalence in a population-based sample of American cancer patients [15], the 15% prevalence in Japanese patients with unrespectable lung cancer in Japan [13], the 18.1% prevalence in Chinese gynecological cancer patients [7], Korean stomach cancer survivors (34.7%)[9], and another study in Korea 20.1% [11] have suicidal ideation. While a study conducted in Turkey showed the prevalence of suicide attempts in cancer patients was 12.74% [5].

A study was carried out in Turkey including 102 patients who were under treatment in the oncology department and the control group included 100 individuals with similar socio-demographic features shows suicide attempts were correlated with depression, anxiety, low level of perceived social support, and advanced stage cancer. Multi-center study performed in Korea showed that poor performance status and having co-morbidity were associated with suicidal ideation and attempt. Performance Status (PS) is a standard functional classification in oncology research and practice. Performance status scores are based on a patient’s ability to perform daily activities and are designed to provide a measure of impairment as a function of cancer. Poor Performance status (defined as Performance status on Eastern Cooperative Oncology Group (ECOG) 2-4 on a 0-4 scale) was determined among cancer patients.

A survey of consecutive patients who attended the outpatient clinics of a regional cancer center in Edinburgh, United Kingdom, shows significant emotional distress, substantial pain, and older age, were associated with a positive response for suicide. Alcohol use, previous suicide attempts, metastatic cancer, palliative care, being male, single, unemployed, diagnoses of more severe types of cancer were significantly associated with suicidal ideation. Additionally, a higher risk of suicidal behavior or ideation was observed during the first 5 years following the initial diagnosis of cancer, and with emotional distress such as depression, hopelessness, anxiety, post-traumatic stress disorder [2, 5, 11, 12, 14, 16-18].

Male patients seem to have a higher suicide risk than females [13]. Cohort studies were carried out among Danish cancer patients which revealed the risk of suicide increase immediately after cancer diagnosis [17 , 19]. Commuting suicide was highest during the first 3 months after the cancer diagnosis for men and from 3 month to 1 year after the diagnosis for women [19].

Patients with terminal cancer have the highest level of hopelessness [15], a powerful predictor of suicidality in cancer patients [8]. In some previous studies, cancer site is also reported to be associated with an increased risk of suicidality [20 , 21].

Despite the rapidly increasing morbidity of cancer [2], to the best of our knowledge, there have been no published studies on the prevalence and associated factors of suicidality among cancer patients in Ethiopia. Therefore, this study assesses the prevalence of Suicidal ideation, attempt, and associated factors among cancer patients.

2. METHODS AND MATERIALS

3. RESULTS

3.3. Prevalence of Suicidal Ideation and Attempt

The prevalence of suicide ideation and attempt among 297 respondents was 83(27.9%) and 25(8.4%), respectively. Of the respondents, 28(37.73%), and 8(32.0%) reported to have suicide ideation, and attempted for ≤ 6 months, respectively (Table 3).

Table 1.

Variables	Category	Frequency(n=297)	Percent (%)
Age	18-27 28-37 38-47 >=48	44 68 78 107	14.8% 22.9% 26.2% 36.1%
Sex	Male Female	150 147	50.50 49.50
Religion	Orthodox Muslim Other	227 58 12	76.43 19.52 4.05
Ethnicity	Tigrigna Amhara Afar	244 32 23	82.13 10.17 7.70
Marital status	Single Married Divorced Widowed	54 184 38 23	18.18 61.95 12.79 7.08
Education status	Non -educated Reading and writing Primary Secondary Diploma and above	18 97 78 45 59	6.10 32.65 26.26 15.13 19.86
Occupation	Unemployed Governmental Private Farmer Student Other	25 60 110 42 48 12	8.41 20.21 37.04 14.14 16.16 4.04
Living status	With family Alone	238 59	80.13 19.87
Monthly income	<1500 1500-4000 4001-7000 >7001	78 75 96 48	26.26 25.25 32.33 16.16

Table 2.

Variables	Category	Frequency(n=297)	Percent (%)
Type of treatment	Chemotherapy Surgery Combined	118 122 57	39.70 41.10 19.20
Duration of illness	≤1years 1-5years ≥5years	184 90 23	61.95 30.30 7.75
Duration of treatment	≤1month 1-3month 3-6month 6-12month ≥12month	21 40 114 92 30	7.10 13.46 38.37 30.97 10.10
Do you have pain	Yes No	168 129	56.56 43.44
If yes did it interfere with daily activity	Yes No	63 105	37.5 62.5
Comorbid medical illness	Yes No	38 259	12.80 87.20
Family history of suicide	Yes No	31 266	10.43 89.57
Depression and anxiety	No, and Borderline* Has depression and anxiety	25 272	8.42 91.58
Ever use substance	Yes No	43 254	14.47 85.53
Which substance?	Alcohol Cigarette Chat Other	20 9 10 4	46.51 20.93 23.26 9.30
Ever use the substance within this three month	Yes No	29 268	9.76 90.24
Which substance	Alcohol Chat Other	12 13 4	41.37 44.84 13.79
How many people are you so close to counting on them during great personal problem?	None 1-2 3-5 ≥5	32 132 112 21	10.74 44.45 37.71 7.10
How much interest do people show in what you do?	very little Little Uncertain Some A lot	30 52 21 122 72	10.10 17.50 7.10 41.10 24.20
How easy is to get practical help from neighbors if you should need it?	Very difficult Difficult Possible Easy Very easy	50 70 58 84 35	16.82 23.57 19.53 28.30 11.78
Oncology performance status	Fully active Restricted in some 50% or more working hour Limited activities	88 148 40 21	29.63 49.83 13.47 7.10

Table 3.

Variables	Category	Frequency(n=146)	Percent (%)
Ever serious thought about commuting suicide	Yes No	83 214	27.94 72.06
Duration of ever serious thought	<=6monthg 6-12month 1-5years >5years	28 38 10 7	33.73 45.78 12.05 8.44
Ever thought of suicide within this 1 month	Yes No	17 280	5.72 94.23
Ever made a plan for commuting suicide	Yes No	29 268	9.76 90.23
Duration of an ever made plan for commuting	<6month 6-12month	12 17	41.37 58.63
Ever attempt of suicide	Yes No	25 272	8.42 91.58
Method used	Hanging Poisoning Jumping from a high place	6 10 9	24.0 40.0 36.0
Duration of ever attempting suicide	<=6month 6-12month >5years	8 10 7	32.0 40.0 28.0
Number of suicide attempted	Once Twice	14 11	56.0 44.0
Ever attempt suicide with this 1 month	Yes No	7 290	2.35 97.65
Reason for attempting suicide	Economic problem Death in the family Mental illness Physical illness	2 5 8 10	8.0 20.0 32.0 40

4. DISCUSSION

Cancer is associated with an increased rate of suicidal acts, suicidal attempts, and suicidal ideation. This leads to commuting complete suicide. The prevalence of suicidal ideation and attempt was 27.9% 95%CI [22.3-31.6], and 8.4% 95%CI [5.2-10.3], respectively. The prevalence of suicidal ideation was higher than the result from studies in the United Kingdom 7.8%[10], Korea 10.9, and 20.1[7,9], Japan 8.6%[14], and 15%[15], Chinese 15.3%[5], and 18.1% [20] the United States 17.7%[18], and lower than a study conducted in Korean 34.7%[7]. The finding of suicidal ideation was lower than the study conducted in Turkey at 12.74%[3].

The prevalence difference in these studies may be due to the difference in sampling methods and design (i.e., case-control, correlation), in the type of cancer (i.e., patients with one type of cancer only vs. various types of cancer), and the study settings (i.e., institutional-based vs. community-based), and in developed countries like Turkey screen early for suicide which gives an increase in prevalence.

Regarding factors associated with suicidal ideation, the result of this study shows that being female was 2.23 times more likely to have suicidal ideation when compared to males. This finding was supported by studies conducted in Korea (26). This might be because females have high suicidal ideation than male counterparts as supported by DSM 5 and other psychiatry books.

The odds of suicidal ideation among stage IV cancer patients were found to be 2.08 times more likely to have suicidal ideation when compared with stage I cancer. This finding was in line with the study conducted in Turkey [3], and Japan(27). This could be due to as the stage of the disease progresses the patient becomes hopeless and end the hope of living.

Patients having depression and anxiety were 2.31 times more likely to have suicidal ideation as compared with those who don’t have borderline depression and anxiety. This finding was in line with various studies like the study conducted in China (20), Japan(15), and(14), USA(28), and the UK (12). This could be due to patients having depression and anxiety was at high risk of suicidal ideation.

The odds of suicidal ideation among participants with poor social support were found to be3.7 times higher as compared to participants with good social support. This finding was supported by studies conducted in China (20), and Canada (29). Social support is one of the protection factors for any mental illness including depression. Therefore those who lack social support were at high risk of depression which leads to suicidal ideation.

Participants with limited performance status were 3.73 times more likely to develop suicidal attempts and ideation as compared with those having fully active status. This finding was in line with a study conducted in the USA(28), Japan (14), UK (12), Canada (29), and Korea(9). This might be due to the reason that a patient who was actively engaging in their daily life becomes dependent on others and they feel hopeless and thinking of ending their life.

CONCLUSION

The prevalence of suicidal ideation and attempt among cancer patients was found to be high, indicating how suicide in cancer patients is a public health problem. Being female, stage IV cancer, having depression and anxiety and lack of social support was associated with suicidal ideation while poor performance status has been associated with suicidal attempt and ideation. Therefore those patients have to find out professional help in early screening and treatment for depression and anxiety, giving social support, and health education on the identification of cancer before progression, especially on females, is crucial for the reduction of suicide.

LIMITATIONS

This study was a cross-sectional study design that cannot show the temporal cause-effect association between factors and suicide. Since this study surveys the whole patient during the study period its default to generalize outside of the study area.

REFERENCES