Cancer and Suicide Among Older Men
(This is a long posting concerning men, cancer, and suicide. I am also
posting the message's substance to forums in America OnLine and to
Internet newsgroups and mailing lists where it might be appropriate.
Because of its length, I suggest that anyone intrigued by the first
paragraph or so *save* the posting to disk and read it offline by word
processor, when convenient. For readers' protection, I usually preface
postings such as this with the caveat that I am a layman, and my expertise
in medicine and all other healing arts is limited to peeling the backing
off a Band-Aid. However, I was a *hotline* volunteer in a suicide
prevention center for a couple of years during *Viet Nam*.)
Every once in a while I am reminded that suicide is a private, silent
and, at times, profound gut reaction to adversity in many men who, like
me, are in their 8th decade or older. The statistics on suicide show that
the suicide rate for white men increases with age, and that white men over
65 are about 4 or 5 times more likely to commit suicide than older white
women. Illness, loss of wife or other life partner, family and financial
difficulties, alcololism, and comparable difficulties intensify a man's
urges toward wanting out.
As a rule, elderly men are suspicious of suicide prevention agencies
(and even distrust family and close friends when it comes to suicide), and
will often resist being drawn into the *prevention* process. In no
uncertain terms they feel that, "It's _my_ business and I'll take care of
it." Yet, we older men do want to understand why we can feel so badly
that killing ourselves is the only answer but, (pardon the pun) we
wouldn't be caught dead checking a book on the subject out of the library,
worse yet, being seen reading it. So unintentionally coming across a
posting on old man suicide while scanning the Internet is maybe OK.
***
I summarized this *professional* article a few years ago in America
OnLine's *SeniorNet* because I thought it was well-written and
understandable. I repeated the posting recently in the Seniornet *men's*
folder in the light of recent postings there by other men in which they
welcomed *health* related discussions that that didn't deride or sneer at
others. Also, there had been quite a few new members since the article
was last posted and discussed. Anyhow, in summary:
***
An article *Suicide and Cancer in Late Life* (Vol. 41, No 12, December
1990) published in the journal *Hospital and Community Psychiatry*
concerned suicide among older men who were, or suspected that they were,
in advanced stages of cancer. The article's authors are Yeates Conwell,
M.D., Eric D. Caine, M.D., and Kurt Olsen, Ph.D. Drs. Conwell and Caine
hold professorships and Dr. Olsen holds an assistant professorship at
prestigious academic or health care institutions.
The article's Abstract, in full, states: *In a controlled
psychological autopsy study of suicide in late life, eight cases in which
the victim's belief that he had cancer played a major role in the decision
to end his life, were examined. All victims were men. The majority had
major affective disorders, but none had been seen in mental health care
settings. Other common characteristics were an active relationship with a
primary physician, numerous losses, prior experience with cancer or
debilitating disease, and a rigid, self-sufficient personality. The cases
illustrate the complex determinants of suicidal behavior in the elderly
and suggest preventive strategies.*
Physical illness is a commonly cited risk factor for suicide,
especially in late life. Of the physical illnesses associated with
suicidal behavior, cancer stands out. (Researcher's name) estimated that
malignant neoplasm was present 20 times more often in his sample of
suicide victims than expected in the general population, and (researcher)
studying suicide and accident victims over age 50, found cancer was
significantly more common among those who took their own lives.
In addition, large scale epidemiological studies have found cancer
patients to be at significantly higher risk for suicide than the general
population. Cancer has a special psychological significance in our
culture, where it is associated with pain, suffering, and death.
The 8 men: One of the 8 was 50 years old and separated, a 71 and a 76
year old were married, and the remaining 5, in their mid to late 70s, were
widowed. The psychological autopsy included interviews with relatives and
friends, and reviews of medical records. Informants described the men as:
Mr. A: Very robust. Strong-willed. Loved to be around people, but had
a short fuse. Very domineering. --- Mr. B: Strict. Precise. Honest.
Friendly independent. Quiet. Withdrawn. --- Mr. C: Self-sufficient,
independent, liked to be needed. --- Mr. D: Isolated and dissatisfied.
Just couldn't take any more disappointments. --- Mr. E: An extremely
stoic, solid guy who never complained. Avoided conflict whenever possible.
--- Mr. F: Jovial, outgoing, but couldn't make decisions. --- Mr. G:
Friendly, but reserved. Obsessed with colostomy care. --- Mr. H:
Conservative, emotionally constricted.
Psychological diagnosis: Five of the 8 men were diagnosed as *Major
depression, single episode.* One, a widower, was *Alcohol abuse, in
remission.* Dependence on alcohol or other intoxicants were indicated for
3 men and 1 had no diagnosis. The men were selected for this report
because of their expressed concerns about cancer. Their experience with
cancer is quoted as follows: Mr. A: Pain due to cancer, fear of
treatment. --- Mr. B: Physical decline associated with belief that his
stomach was *loaded with cancer.* --- Mr. C: Wife died of uterine
cancer in 1982; physical decline associated with belief that the colon
cancer (he had in 1983) was terminal, *he was fatalistic.* --- Mr. D:
Somatic preoccupation: *I might have cancer, but nobody's cutting me
open.* --- Mr. E: Close friend recently died after one-year
hospitalization; increasing abdominal pain; was convinced *something was
seriously wrong.* --- Mr. F: First wife died of cancer in 1973; cousin
died of cancer in 1987; physical decline with diarrhea; *he thought he
had cancer.* --- Mr. G: Wife died of cancer in 1987; deterioration of
health associated with belief that he had recurrent cancer. --- Mr. H:
Wife died of cancer in 1983; discovered blood in his stool and assumed he
had recurrent cancer. --- Mr. H survived an attempt at suicide and was
included in the study because he was a unique source of data.
Three of the cases were presented in detail: Mr. B, Mr. C, Mr. H.
Case 1. Mr. B was a 77 year-old who killed himself with a gunshot to
the head. His wife had died in 1969 of multiple sclerosis, for which he
had provided assiduous care at home. Despite subsequent losses, including
the death of his only son and a favored nephew and his daughter's
diagnosis with multiple sclerosis, Mr. B functioned well socially.
However, his physical state was progressively more compromised by
emphysema. Mr. B stated repeatedly to his friends that he would not
tolerate becoming a burden on others as his wife had been. *When I get
that way,* he said, *I will take the bullet.*
During his last several months of life, Mr. B became more withdrawn.
After a flu-like illness, he complained increasingly of stomach and head
pains, sleep and appetite disturbance, and anxiety. His friends reported
that he seemed preoccupied, and he revealed to them the day before his
death that he thought his stomach was *loaded with cancer.* There were no
other indications of impaired reality testing. He had no prior history of
suicidal behavior or psychiatric illness or concerns, and he drank
infrequently.
Mr. B had always avoided doctors, but with the apparent change in his
health during his last weeks, he was persuaded by family and friends to
see a physician. An appointment was scheduled for the day of his death.
When a friend arrived at his home to take him to the appointment, she
found him dead. A physical autopsy was not performed. Therefore, although
Mr. B's symptoms and course were consistent with a single episode of major
depression, (we) were unable to specify the relationship between his
affective disorder and his physical condition.
Case 2: Mr. C was a 77-year old widowed white man who had lived alone
since his wife's death in 1982 after a protracted struggle with uterine
cancer. After a brief and appropriate grief he began to travel, an
activity he enjoyed until one year later, when he received a diagnosis of
cancer of the colon. He underwent treatment but refused the recommended
colostomy and developed incontinence of both urine and stool. Therefore,
due to incontinence, chronic obstructive pulmonary disease, cataracts, and
hearing deficits, he became increasingly withdrawn and restricted in his
activities. He had no history of suicidal behavior or psychiatric
contacts, and he rarely drank.
Throughout life Mr. C had made such comments as, *When I get old and I
can't do for myself, put a gun to my head.* During the last four months
of his life he rapidly declined. He had pronounced anhedonia, anorexia,
weight loss, and loss of concentration and energy. Four days before his
death, he saw his primary physician at his daughter's insistence.
Impressed by Mr. C's deterioration, the physician scheduled a hospital
admission for further evaluation. The next day Mr. C killed himself with
a gunshot to the head. His family believed that he took this action with
the perception that he was terminally ill with metastatic colon cancer.
An autopsy showed only pulmonary emphysema; there was no evidence of
recurrent tumor. Our consensus diagnosis was major depression, single
episode, without psychotic features.
Case 3. Unlike the preceding subjects, Mr. H failed in his attempt to
take his life. He provided the following history during an inpatient
hospitalization after his suicide attempt. Mr. H was a 78-year old white
man who had moved from his home to a senior citizen's apartment complex in
1986 following a series of losses -- his wife's death in 1983 from
metastatic cancer, a right hemispheric stroke with residual hemiparesis,
and a surgical resection for treatment of bowel cancer in 1985. He had no
prior history of suicide attempts or psychiatric illness.
One week before his suicide attempt, Mr. H discovered blood in his
stool. Concluding that his cancer had returned and that he would die
following a protracted and painful course, he carefully planned his death.
On the morning of his attempt, Mr. H left his family a note and money for
anticipated expenses, drove his car to a municipal parking lot, and shot
himself in the left side of the chest. The bullet, which exited at the
tip of the left scapula, narrowly missed his heart. He was discovered
several hours later. During the subsequent hospitalization, his
hematochezia was diagnosed as bleeding hemorrhoids. Mr. H was without
somatic delusions and gratefully accepted the fact that there was no
cancer recurrence.
Discussion (excerpts): The conclusion drawn here must be considered
cautiously, in light of the small sample size and retrospective
methodology. In addition, we can define no appropriate subject group for
direct comparison. The sample included patients with cancer and those
with the unverified belief that they had the illness. Our concern is not
solely whether cancer places an individual at risk for suicide, but
whether the belief or perception that one has a terminal illness
constitutes such a risk. We seek to understand how these individuals may
have been predisposed to their apparently lethal beliefs and to recognize
the implications of the cases for clinical practice and suicide
prevention.
A second link between suicide and the belief that one has cancer may be
provided by the observation that loss and a prior experience with cancer
or other debilitating chronic illness were common factors among our cases.
Three of the eight subjects had a prior personal history of colon cancer
(Mr. C, G, and H), and the wives of four had died of cancer (Mr. C, F, G,
and H). Two others (Mr. B and E) had lost a wife or close friend to other
debilitating diseases. The effects of chronic and deteriorating illnesses
were, therefore, familiar to most subjects and were feared. As Mr. H
stated, *I don't want to die a lingering and painful death like my wife.*
The fear of cancer was far more prominent than its reality.
Conclusion: (excerpted) The understanding of suicide in late life must
go beyond the presence or absence of associated physical or psychiatric
illness to include considerations of coping style, long-term functioning,
and personal values. Physicians must not be quick to adopt the view that
suicide is, in any instance, a simple matter. Rather, as these cases
illustrate, suicide is a multifactorial process. Although superficially
understandable, these deaths caricature *rational suicide*: the victims
often were clinically depressed, and they uniformly exaggerated the
medical significance of their symptoms.
Early in the course of their medical school education physicians should
be trained to diagnose and treat depressive disorders in late life, being
particularly alert for atypical somatic presentations in previously
high-functioning, non-psychiatric patients. Furthermore, our training
centers should reexamine their commitment to the patient-centered
approach. In this age of technological medicine and cost containment, the
clinician must be alert to the latent content of our interactions with
patients. To avoid the elaboration and distortion that characterized the
thinking of the eight men we described, clinicians must actively elicit
their patients' perceptions, apprehensions, and experiences relating to
cancer and other debilitating illnesses. They must take time to explore
their patients' fears regarding loss of autonomy and vigor and increase of
pain.
Finally, on the scale of national health policy, we must educate the
general public about the relationship of depressive disorders,
hypochondriasis, and suicide risk; demythologize cancer, and establish
reimbursement mechanisms that value the personal, time-consuming
interchanges between the primary care physician and the patient through
which psychotherapeutic intervention can be made.
***
