The trait anxiety as a predictor of the suicidal risk in patients with cancer

Abstract

Studies investigating the psychological aspects of cancer have gained importance in recent years. In these studies, the rates of depression and anxiety in cancer patients were examined, but the risk of suicide had not been examined. This study investigated the psychiatric diagnoses of depression, anxiety, and suicide risk in cancer patients. Eighty patients who met the inclusion criteria were administered the Beck Depression Inventory, State-Trait Anxiety Inventory, Structured Clinical Interview for DSM (SCID), and Suicide Probability Scale. The examination of the relationships across variables was assessed with Pearson's correlation analysis and stepwise multiple regression analysis. Due to SCID assessment, 45% of patients were found to have depression diagnosis, and 11.25% were found to have anxiety diagnosis. In the patients who had previous psychiatric diagnosis and treatment, total suicide probability scores demonstrated statistically significant differences. The frequency of depressive disorders and anxiety disorders in cancer patients is high. The studies investigating that suicide are rare, and in our findings, previous psychiatric diagnosis and treatment were risk factors. In the past studies, depression has been reported to be the most important factor in increasing the risk of suicide in cancer. Contrary to previous findings, according to the data obtained from this study, anxiety is the most important predictor of suicidal risk among all the determinants.

INTRODUCTION

It is well known that cancer is a difficult illness that affects the patient and the family physically and emotionally. The coping of the patient with this stress depends on a variety of factors. These factors include medical (type, duration, and prognosis of the illness), psychological (capacity for physical and psychological rehabilitation), and interpersonal (the presence or absence of individuals providing emotional support) aspects.[1,2,3] Psychological symptoms that develop after cancer diagnosis are important for their effect on the severity of medical condition, duration, response to treatment, quality of life, and compliance with treatment.[4]

In cancer patients, the most common psychiatric disorders are major depression, anxiety disorders, adjustment disorders accompanied by depressive symptoms, and depression related to a medical condition. In cancer patients, depression ranges from isolated depressive symptoms to major depressive disorder.[5] In a variety of studies, the cancer diagnosis has been reported to be a risk factor for suicide. According to the population-based cancer studies, suicide risk in cancer patients is 1.3–2.6 fold (2 fold on average) higher compared to the general population.[6,7] While this risk is at the highest level in early times of the diagnosis, a study showed that the risk for suicide continued even after 30 years after a breast cancer diagnosis. Furthermore, it was reported that suicidal ideation and attempts were frequent in childhood cancer patients after 20 years from the treatment.[8]

Several factors that are related with suicide in cancer patients are diagnosis of cancer at an early age, application of radiotherapy on the head, worsening of physical appearance, and impairment in memory and cognitive functions. As for cancer survivors, there are problems associated with being exposed to medical treatments such as chronic pain, possible infertility, heart problems, and cognitive disability.[8]

In addition, suicide risk increases in the advanced stage of the illness, bad prognosis, mild delirium condition that causes impulse control problems, insufficiently controlled pain, depression, history of psychiatric or personality disorder, physical and emotional burnout, and detachment from the society.[1] The aim of this study is to investigate the predictors of suicidal risk in cancer patients.

PROCEDURE

Participants

Patients who applied to radiation oncology policlinics at the Near East University Hospital with the diagnosis of cancer between May 2015 and May 2016 and who volunteered to participate were included in the study. Necessary permission and approval were obtained from the ethical committee of medical faculty before the study (YDU/2013/17-91). Written informed consents were obtained from all the participants. Patients were in the age range of 33–79 years. In patients, the presence of mental retardation, presence of neurological disorder, presence of psychotic disorder, unawareness of cancer diagnosis, presence of alcohol, and substance dependence constituted the exclusion criteria. Patients were administered Beck Depression Inventory (BDI), State-Trait Anxiety Inventory (STAI), Structured Clinical Interview for DSM (SCID), and Suicide Probability Scale (SPS).

Instruments

Clinical measures

Beck Depression Inventory

It measures bodily, emotional, and cognitive symptoms that are seen in depression. It is a 4-point Likert type 21-item self-assessment scale. The highest score that can be obtained is 63. Higher scores indicate the severity of depression. Turkish reliability and validity were investigated by Hisli.[9]

Structured Clinical Interview for DSM

SCID-I is a structured clinical interview developed in 1997 for DSM-IV disorders.[10] It is an interview chart covering DSM-IV diagnoses, and its Turkish reliability and validity analysis were conducted by Çorapçıoǧlu et al.[11]

State-Trait Anxiety Inventory

The scale which measures state and trait anxiety levels with 20 items was developed by Spielberger et al. in 1970, and Turkish adaptation was performed by Oner and Le Compte in 1985. Higher scores indicate high anxiety levels, whereas low scores indicate lower anxiety.[6]

Suicide Probability Scale

It is a four-point Likert-type self-assessment scale with 36 items, and it was developed by Cull and Gill.[7] Adaptation to Turkish, validity and reliability studies were carried out by Atlı et al.[12] The aim of the scale is to assess suicide risk in adolescents and adults. The higher scores obtained from the scale indicate a higher probability of suicide.

Statistical analysis

The analysis of the data obtained from the patient groups was performed using the “SPSS Statistics 21.0 (IBM Corp., Armonk, NY, USA)” statistical package program. In the preliminary step, variables were checked for the assumptions of parametric statistical testing by the visual analyses of distribution plots and Wilks–Shapiro tests. The Chi-square test was used to compare the categorical data, and the independent t-test and one-way ANOVA from the parametric tests were used to compare the numerical variables of groups, and the relations between variables were examined by the Pearson's correlation tests. We hypothesized that significant correlations identified possible predictors, and therefore, a stepwise multiple regression analysis was conducted with these possible predictors to determine the best predictors of suicide probability. Each variable was entered into the multiple regression analysis if its F value was >4. P <0.05 was considered statistically significant.

RESULTS

Descriptive characteristics of the patients

The patients' distributions regarding their cancer diagnosis are 4 hematologic cancer, 6 genital cancer, 11 with gastrointestinal cancer, 4 lung cancer, 28 breast cancer, 8 head-and-neck cancer, 1 skin cancer, 6 brain cancer, and 8 cancer with primary unknown, respectively. The mean age of the participants is 54.41 ± 11.02 years. It was determined that there was no statistically significant difference between scores obtained from the scales with respect to age groups. Similarly, it was determined that there was no statistically significant difference between scores obtained from the scales with respect to marital status groups. Moreover, we estimated that there was no statistically significant difference between scores obtained from the scales with respect to educational status. Finally, it was found that there was no statistically significant difference between scores obtained from the scales with respect to the duration in which patients learned their diagnosis. Descriptive characteristics of the patients are outlined in Table 1. The mean scores of the cancer patients were 17.46 ± 14.28 for BDI, 43.54 ± 11.85 for state anxiety, 52.95 ± 15.15 for trait anxiety, and 64.14 ± 13.14 for SPS.

Table 1.

Descriptive characteristics of patients and the comparison of suicide probability of patients with respect to patients’ descriptive characteristics

Characteristics	Variable	n	x̅	s	t	P
Gender	Women	51	61.39	13.45	1.28	0.20
	Men	29	65.24	11.85
Education (years)	8 and less	44	60.59	12.09	−1.69	0.94
	8 and over	36	65.47	13.62
Surgery	No	16	66.93	11.69	1.44	0.15
	Yes	64	61.75	13.13
Radiotherapy	No	1	68.00	-	0.40	0.68
	Yes	79	62.72	13.02
Chemotherapy	No	13	61.53	13.43	−0.37	0.70
	Yes	67	63.02	12.95
Time of diagnosis (months)	>6	46	64.60	12.46	1.47	0.14
	<6	34	60.32	13.38
Metastasis	No	72	62.45	13.10	−0.67	0.49
	Yes	8	65.75	11.85
Marital status	Married	60	62.88	13.31	0.11	0.91
	Single	20	62.50	12.14
Stage of cancer	Low	52	61.78	12.62	−0.93	0.35
	High	28	64.64	13.58
Previous psychiatric diagnosis and treatment	No	61	61.00	9.75	2.26*	0.02
	Yes	19	68.52	10.98

*P<0.05

The Differences between assessed variables across groups

The comparison of suicide probability of patients with respect to patients' descriptive characteristics and SCID diagnosis is presented in Tables 1 and 2, respectively.

Table 2.

Comparison of patients suicide probability scale scores with respect to diagnosis

Scale	SCID	n	x̅	s	Sum of squares	df	Mean square	F	Significant	Suicide risk
SPS	No diagnosis	35	57.17	13.24	2439.44	2	1219.72	8.67**	0.005	No diagnosis < depression No diagnosis < anxiety Depression=anxiety
	Depression	36	65.52	11.46
	Anxiety	9	73.66	5.70

**P<0.01. SCID – Structured clinical interview for DSM; SPS – Suicide probability scale

Predictors of suicidal risk

The correlational analyses revealed that there was significant relationship between SPS and BDI (r = 0.27, P = 0.01) and state anxiety (r = 0.56, P < 0.01) with trait anxiety (r = 0.58, P = 0.05). For the second step, SPS was regressed on the significant variables. Neither state anxiety (F(3,76) =22.33, P = 0.21) nor BDI scores (F(3,76) =14.71, P = 0.28) were significant. Only the trait anxiety subtest (F(3,76) =34.84, P = 0.04) was significant. As a result, trait anxiety subtest predicted the SPS.

CONCLUSION

In this study, there was a statistically significant difference between scores obtained from the suicidal probability scale in patients with and without previous psychiatric diagnosis; and a significant difference was determined in depression and anxiety scores. The variable of having psychiatric history was also considered as a risk factor in previous studies.[13] As previous studies found that anxiety and depression are common emotional experiences of progressed cancer patients,[14] the levels of these features should be continuously observed.[15] High anxiety and depression reduce people's quality of life[16] and may lead to negative outcomes, such as suicidal thoughts and suicide-related behaviors.[17] In this study, there was a positive correlation between suicide probability, depression, and anxiety. However, the final statistical analyses revealed that the trait anxiety is the most important predictor of suicidal risk among all these determinants. Consequently, anxiety disorders need to be investigated more in cancer patients.

It was reported that in cancer patients, suicide attempt is associated with depression, hopelessness, prior psychiatric illness and suicidal act, alcohol and substance abuse, history of suicide in the family, uncontrollable pain, multiple physical symptoms, advanced stage of the illness, bad prognosis, delirium, male gender, being single, being unemployed, isolation, and lack of social support.[18] Despite previous findings, we did not find any differences between female and male patients' scores of depression and anxiety. In addition, with respect to age groups, marital status, and educational status, there was no difference in the suicidal probability scale. There was no difference with respect to stage of the illness. More studies are required to identify risk factors for suicide. Our findings suggested that the identification and treatment of mental disorders may not only improve a cancer patient's quality of life but also contribute to reducing the risk of suicide.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.