Is post-diagnosis suicide risk in cancer patients related to psychological or physical factors?

I have been thinking and learning a lot about suicide risk in cancer patients because I am working with some colleagues in cancer control and prevention to identify and respond to educational needs among cancer care professionals. Related to this topic, readers might be interested a nice article by Kendal & Kendal published last year in the journal Crisis (abstract linked below). This article titled, Comparative Risk Factors for Accidental and Suicidal Death in Cancer Patients makes a number of insightful observations about risk in cancer patients based on statistical analyses of a large and impressive NCI dataset (SEER, 1973-2000).

Among the observations I found most interesting was that the well-documented increased risk of suicide in the year following cancer diagnosis, which is commonly attributed to psychological factors, may in fact be more closely related to physical factors, i.e. rapid deterioration of symptoms in rapidly progressing disease. Because many of the candidate psychological factors were not measured in this study, the question cannot be studied directly, but I found the findings compelling enough–and their treatment in the article careful enough–to warrant consideration. In the end, it may be very difficult to tease apart psychological distress from physical suffering, but I appreciate this article drawing attention to the question.

Citation: Kendal WS & Kendal WM (2012). Comparative risk factors for accidental and suicidal death in cancer patients. Crisis: The Journal of Crisis Intervention and Suicide Prevention. 33(6):325-34. doi: 10.1027/0227-5910/a000149.

Resource re: means restriction in practice

I've had a nice response to the brief commentary I posted in conjunction with a link to the NY Times article about means restriction.  In light of that, I thought I'd post a link to the a site called Means Matter, which is published by the Harvard Injury Control Research Center.   The site has summary pages called "Taking Action" for families, communities, and clinicians.

The talking action page for clinicians is worth reading for any clinician, and could be especially useful to primary care providers.  I'm thinking a lot about primary care right now because (a) primary care psychology has beeen a focus of my career and I have a deep respect for the breadth of responsibility primary care providers carry, including in suicide prevention (b) I'm still pondering the recent question I considered about self-trasport and (c) I'm presenting a talk titled "Tips for Suicide Risk Assessment and Response in Primary Care" next month at the Highland Family Medicine center here in Rochester.

"Trusting" a person at risk who agrees to transport self

A colleague  forwarded me the following excellent question posted to a listserv:
One question that has been raised is how to handle an individual who reports willingness to voluntarily go to the ER for psychiatric assessment.  Since trusting a questionably unstable and suicidal individual to present for treatment opens our agency and the patient up to considerable risk, I wanted to get input on this issue from professionals in the field.

My questions are: What is the process that you use when you genuinely believe an adult patient will voluntarily present her/him self for possible commitment/assessment?  How do you manage patient risk and your own liability in this instance? (e.g . requiring family members to be involved; or requiring a signed written contract to present at the hospital, etc) What do you do to ensure/confirm that they do indeed go to the hospital? What do you do when they do not go to the hospital, as agreed?

I'm looking for both a description of specific steps that you take and what variables you take into consideration as you decide what to do in this case.

This is an excellent question for several reasons:

  • the writer wants to support patient agency, preferring in principle to go with the patients voluntary wishes, rather than become unnecessarily coercive.

  • the writer is correctly concerned about putting all eggs in the self-report basket.   A person at risk who is not stable may not be able to follow through with intentions to get help.   It is central to both really listen people in our care AND understand that self-report has limitations and has to be considered in context

  • the writer has shared honestly her concern about both patient safety and his/her own liability—almost everyone who works with individuals at risk has these dual concerns and needs to think openly about how to balance them.

This is such a good question that I wish I had put it on my docket of questions to blog about.  And it relates as a follow-up question to one that is on that docket, "When it comes to hospitalizing isn’t it always best to “err on the side of caution”?

Here is my attempt to offer some principles for the assessment and documentation of a patient's agreement to voluntary actions:

  • Document assessment of reliability of self-report.  When assessing and documenting self-report the following should be considered and noted:

    • past experience, if any with the patient as a reliable reporter or not.   “Pt. has reliably followed through on medical decisions and plans in the past.”

    • evidence of psychosis, thought disorder, intoxication, extreme agitation or other factor that would put the person’s capacity to make decisions in question.   If not, “Pt’s thinking is logical, coherent, and reasonable.  Judgment is intact.   No indication of impaired capacity to make decisions and follow through with them.”

    • degree of patient cooperation.  Explicitly note that the person volunteered information, though s/he didn’t have to.   “The patient has been open, cooperative, and collaborative in the assessment and planning process.  There is little reason to doubt his/her sincerity in agreeing to seek help and additional evaluation.”

    • impulsivity.   The greatest risk here would be that the person would all of a sudden feel overwhelmed with pain and impulsively kill him/herself.  If there is not strong evidence of that kind of impulsivity (even if there has been some in the past) note that.  “The patient has a past history of mild impulsive behavior, however, this was several years ago and under very different circumstances..."

  • Show your reasoning.  The key to great documentation is to state each of the factors considered, then show that the plan came as a result of synthesizing these factors.  This can come in a statement like “In light of these factors, the plan for voluntary self-transport seems reasonable and prudent.”

  • Say what you didn't do.  Related to the previous point, it as as important to document the road NOT taken.   This shows that you took the situation seriously and considered the full range of options.

    • A corollary to this principle is to note risks associated with alternative courses of action.   “Involuntary transport has potential of violating the patient’s rights and of harming the patient’s opportunity to benefit from hospitalization.   The risk associated with involuntary transport outweigh the relatively small risk that the patient will precipitously abandon our plan and harm him/herself.”

  • Document consultation.   Much more consultation occurs in primary care than is ever documented.   This would be a time to do it.  One line is sufficient:  “Discussed case with Dr. X who concurred with the plan.”

Note that each of these points needs only a sentence or bullet-point, and not all will be applicable in every circumstance.

I'd be interested in feedback and ideas from who employs these principles in their documentation.  I would also be interested in reading comments with other ideas about how to address the situation the questioner described.

How we think about Primary Care "Gatekeepers"

Primary care physicians are often grouped in as "gatekeepers," who need to be able to ask about suicide, know warning signs, and refer. The tend not to get in-depth training about formulating or documenting risk assessments.

The problem with this "gatekeeper" view is that we don't have the kind of seamless system that allows the primary care professional the luxury to leave the judgment call to a mental health professional. It's not like they are standing at a gate, able to wave a patient on to a mental health professional on the other side. There are barriers to access, patients who refuse evaluations, and the need to make decisions about who warrants intrusive involvement and who does not. These are sophisticated clinical judgments that go beyond "know the warning signs." PCPs have to be able to articulate an evidence-based rationale for allowing a patient to go home with an outpatient appointment versus involving a psychiatric emergency team.

I met with a group of pediatric primary care professionals this week. Our discussion brought this point home to me. They were eager to be trained in true risk formulation and documentation--and felt that these skills would help them feel less anxious about asking about suicide.

There may be some gatekeepers for whom instruction in questions, warning signs, and referral options is enough. But primary care gatekeepers need more.