Decreasing suicide risk among patients with prostate cancer: Implications for depression, erectile dysfunction, and suicidal ideation screening

doi:10.1016/j.urolonc.2017.09.007

Urologic Oncology: Seminars and Original Investigations

Volume 36, Issue 2, February 2018, Pages 60-66

https://doi.org/10.1016/j.urolonc.2017.09.007 Get rights and content

Highlights

•
Men with prostate cancer are at increased risk for suicidal death.
•
Use of ADT is associated with depression in men with prostate cancer.
•
Erectile dysfunction after curative therapy is associated with clinical depression.
•
A new screening algorithm assesses for ED, depression and suicidal risk.

Abstract

Objective

Prostate cancer is the most common malignancy among males, accounting for 19% of cancers, and the third most common cancer-related cause of death. Suicide rates in the United States have increased among males over the last decade. Further, suicide rates are higher in oncology patients, including patients with prostate cancer, compared to the general population. The objective of this article is to review the current literature and address the relationship between prostate cancer, depression, erectile dysfunction, and suicidal ideation.

Materials and methods

We reviewed the current literature pertaining to prostate cancer and depression, and prostate cancer and suicide. Furthermore, associations were made between erectile dysfunction and depression.

Results

Men with prostate cancer at increased risk for suicidal death are White, unmarried, elderly, and men with distant disease. Time since diagnosis is also an important factor, since men are at risk of suicide>15 years after diagnosis. Approximately 60% of men with prostate cancer experience mental health distress, with 10%–40% having clinically significant depression. Additionally, patients that received androgen deprivation therapy (ADT) are 23% more likely to develop depression compared to those without ADT. Longitudinal studies of prostate cancer patients suggest that erectile dysfunction after curative treatment may have a significant psychological effect leading to depression. Herein, a newly proposed screening algorithm suggests for an evaluation with the expanded prostate cancer index composite-clinical practice, patient health questionnaire-9, and an 8-question suicidal ideation questionnaire to assess for health-related quality of life, depression, and suicidal ideation.

Conclusion

The burden of screening for erectile dysfunction, depression and suicidal ideation lies with the entire health care team, as there appears to be an association between these diagnoses, that is, compounded in patients with prostate cancer. The screening algorithm should assist with guiding timely and appropriate psychiatric referral to optimize outcomes in these high-risk patients.

Introduction

In 2017 in the United States, there will be an estimated 161,360 new cases of prostate cancer and approximately 26,730 deaths [1]. Prostate cancer is the most commonly diagnosed malignancy among males, accounting for 19% of all cancers, and the third most common cancer-related cause of death [1]. Although localized prostate cancer is highly curable, this is often associated with significant, life-altering side effects including urinary, bowel, and sexual dysfunction [2], [3].

According to the World Health Organization (WHO), more than 800,000 individuals worldwide commit suicide on a yearly basis [4]. Furthermore, the National Institute of Mental Health has reported that suicide rates in the United States have increased among males, from 19.0 per 100,000 in 2008 to 20.7 per 100,000 in 2014 [5]. Suicide rates have been reported to be higher in oncology patients compared to the general population [6] (31.4 suicides per 100,000 [7]), including patients with prostate cancer [8], [9], [10] (48.3 suicides per 100,000 [9]). Together with an estimated 16.1 million American adults suffering from at least one major depressive episode per year [11], these statistics have important implications for the mental health and quality of life of long-term prostate cancer survivors.

A review of the risk factors for repeated suicide attempts by Beghi et al. has shown an association between suicidal ideation and death, white ethnicity, older age, male gender, and living alone [12]. Most prostate cancer patients fit aspects of this demographic profile (white, older age, and male), in addition to potentially having other treatment related side effects, such as erectile dysfunction, incontinence, bowel dysfunction and depression, that may increase their suicide risk. As such, identifying and screening these patients for suicidal ideation is important. To date there has been a paucity of literature highlighting screening methods for depression and erectile dysfunction among patients with prostate cancer. The objective of this article is to provide a narrative review of the current literature and address the relationship between prostate cancer, depression, erectile dysfunction, and suicidal ideation. Further, we propose a screening algorithm for identifying these patients who may be at increased risk for suicidal death.

Section snippets

Methods

We conducted a comprehensive literature search using Medline, PubMed, and reviewing references from pertinent articles. A combination of keywords (focusing on an association with prostate cancer) were used, such as “suicide,” “depression,” “erectile dysfunction,” and “screening.” For the results (Section 3, I–IV), there were 91 articles that were reviewed, 67 of which were downloaded and 24 identified from references. Among these articles, 76 were excluded (27 secondary to reviews/editorials,

Prostate cancer and suicide

The first population-based study analyzing suicidal death in prostate cancer patients was based on data from the Prostate Cancer Database Sweden (PCBaSe) [9]. The PCBaSe includes 97% of all prostate cancer cases derived from the National Prostate Cancer Register of Sweden from 1997 to 2006. In this cohort study, 77,439 men with prostate cancer were age-matched to Swedish men without prostate cancer. There were 128 suicides with a suicide rate of 48.3 per 100,000 person-years in the prostate

Clinical implications

It is imperative to take a multidisciplinary approach, utilizing all members of the health care team, when evaluating patients with prostate cancer for depression and suicidal ideation. The American Cancer Society guideline for prostate cancer survivorship highlights a multidisciplinary approach to long-term physical and psychosocial well-being [38]. For example, in addition to clinicians and nurses in the prostate cancer clinic, other clinicians such as mental health professionals trained in

Conclusion

Suicide in patients with prostate cancer is not an uncommon event and may occur many years after diagnosis. Up to 5%–12% of patients may have suicidal ideation, particularly those who are white, unmarried, elderly and have distant disease. Approximately 60% of patients with prostate cancer will develop depression or mental health illness and there appears to be an association between erectile dysfunction and depression that is compounded in patients with prostate cancer. The burden of screening

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Cited by (49)

Racial Disparities in Diagnosis and Treatment of Depression Associated with Androgen Deprivation Therapy for Prostate Cancer
2024, Urology
To analyze potential racial disparities in the diagnosis and management of depression associated with androgen deprivation therapy.
TriNetX health record network was queried for prostate cancer patients treated with androgen deprivation therapy from 2003-2023. Differences in rates of depression diagnosis and treatment were compared between White and Black patients. Means, odds ratios, and t tests were calculated in univariate analysis with 95% confidence intervals (CI).
Data were queried from 93 health care organizations to yield 78,313 prostate cancer patients treated with androgen deprivation therapy. Patients on androgen deprivation therapy had 60% greater odds of developing depression vs other patients [9% vs 6%; odds ratio (OR) 1.6; 95% CI (1.5-1.7); P <.0001]. Of those with depression secondary to androgen deprivation therapy, only 35% were treated with antidepressants. After starting androgen deprivation therapy, White patients had 30% greater odds of being diagnosed with depression, compared to Black patients [10% vs 8%; OR 1.3; 95% CI (1.2-1.4); P <.001]. White patients also had higher odds of being treated with a first line antidepressant than Black patients [56% vs 48%; OR 1.4, 95% CI (1.2-1.6), P <.001].
This analysis confirms a significant association between androgen deprivation therapy and the development of clinical depression, and highlights its medical undertreatment. Importantly, our findings also indicate significant racial disparities in the identification and treatment of depression. Routine screening initiatives that account for social determinants of health may alleviate this disparity. Limitations of this study include retrospective design and lack of data describing severity of depression, which might correlate with need for medication.
Impact of Prostate Cancer-related Genitourinary Radiation Injury on Mental Health Diagnosis and Treatment: Assessment of 55,425 Men
2024, Urology
To investigate the association of low-grade radiation injury (LGRI) and high-grade radiation injury (HGRI) following prostate cancer treatment with mental health diagnoses and therapy.
A retrospective study of men diagnosed with prostate cancer who were treated with radiotherapy. Men were followed to assess for LGRI or HGRI using IBM MarketScan. Cohorts included: no injury (no-RI), LGRI, HGRI, and controls. Mental health diagnoses and related treatment (medication/therapy) were identified using ICD-10 codes, CPT codes, and national drug codes. A multivariable Cox proportional hazards model from time of radiation to first instance of mental health diagnosis was modeled against injury group, age, and comorbidities.
Between 2011 and 2020 we identified 55,425 men who received radiotherapy for prostate cancer. 22,879 (41.3%) experienced a LGRI while 4128 (7.4%) experienced a HGRI. Prior to radiation therapy, mental health diagnoses were equally distributed across cohorts (P > .05). Every marker of mental health showed a step-wise increase in incidence from no-RI to LGRI to HGRI except for alcohol abuse. Use of mental health medications and therapy visits were slightly more likely in the LGRI and HGRI groups prior to radiation, however, this difference was greatly increased postradiation therapy. LGRI (HR 1.38; P < .001) and HGRI (HR 2.1; P < .001) were independently associated with an increased likelihood of mental health diagnoses.
LGRI and HGRI following prostate cancer radiotherapy are associated with increased risk of mental health diagnosis, medication use, and therapy need compared to men who do not develop injuries. The most common mental health diagnoses were depression and anxiety.
Long-term Risks of Depression and Suicide Among Men with Prostate Cancer: A National Cohort Study
2023, European Urology
A diagnosis of prostate cancer (PC) may cause psychosocial distress that worsens quality of life; however, long-term mental health outcomes are unclear.
To determine the long-term risks of major depression and death by suicide in a large population-based cohort.
This was a national cohort study of 180 189 men diagnosed with PC during 1998–2017 and 1 801 890 age-matched, population-based, control men in Sweden.
Major depression and death by suicide were ascertained from nationwide outpatient, inpatient, and death records up to 2018. Cox regression was used to compute hazard ratios (HRs) adjusted for sociodemographic factors and comorbidities. Subanalyses assessed differences by PC treatment during 2005–2017.
Men diagnosed with high-risk PC had higher relative rates of major depression (adjusted HR [aHR] 1.82, 95% confidence interval [CI] 1.75–1.89) and death by suicide (aHR 2.43, 95% CI 2.01–2.95). These associations persisted for ≥10 yr after PC diagnosis. The relative increase in major depression was lower among those treated with radiation (aHR 1.44, 95% CI 1.31–1.57) or surgery (aHR 1.60, 95% CI 1.31–1.95) in comparison to androgen deprivation therapy (ADT) alone (aHR 2.02, 95% CI 1.89–2.16), whereas the relative rate of suicide death was higher only among those treated solely with ADT (aHR 2.83, 95% CI 1.80–4.43). By contrast, men with low- or intermediate-risk PC had a modestly higher relative rate of major depression (aHR 1.19, 95% CI 1.16–1.23) and higher relative rate of suicide death at 3–12 mo after PC diagnosis (aHR 1.88, 95% CI 1.11–3.18) but not across the entire follow-up period (aHR 1.02, 95% CI 0.84–1.25). This study was limited to Sweden and will need replication in other populations.
In this large cohort, high-risk PC was associated with substantially higher relative rates of major depression and death by suicide, which persisted for ≥10 yr after PC diagnosis. PC survivors need close follow-up for timely detection and treatment of psychosocial distress.
In a large Swedish population, men with aggressive prostate cancer had higher long-term relative rates of depression and suicide.
Marital status and perceived stress in men with advanced prostate cancer: A randomized-controlled trial of cognitive behavioral stress management
2023, Journal of Psychosomatic Research
Relationship status predicts numerous outcomes among medical populations. Few interventions evaluate the role of marital status on response to psychosocial treatment, and no such studies exist within advanced prostate cancer (APC). This study examined whether marital status modified the effect of a cognitive behavioral stress management (CBSM) intervention on perceived stress.
Men with APC (N = 190) were randomized to 10-week CBSM or a health promotion (HP) intervention (#NCT03149185). The Perceived Stress Scale assessed perceived stress at baseline and 12-month follow-up. Medical status and sociodemographics were captured at enrollment.
Participants were mostly White (59.5%), non-Hispanic (97.4%), heterosexual (97.4%) men, 66.8% of whom were partnered. Neither condition nor marital status predicted perceived stress change at follow-up. However, a significant interaction was found between condition and marital status (p = 0.014; Cohen's f = 0.07), such that partnered men who received CBSM and unpartnered men who received HP reported greater reductions in perceived stress.
This is the first study to assess the impact of marital status on psychosocial intervention effects among men with APC. Partnered men derived greater benefit from a cognitive-behavioral intervention and unpartnered men equally benefitted from a HP intervention. Further research is necessary to understand the mechanisms underlying these relationships.
Subclinical inflammation as a predictor for erectile dysfunction after brachytherapy for localized prostate cancer
2022, Brachytherapy
Citation Excerpt :
Notably, erectile dysfunction (ED) is common following different treatments for localized PCa and can have a potentially significant effect on patients’ quality of life and mood. The prevalence of ED among PCa patients treated with different monotherapies is variable (2). We previously reported favorable preservation of erectile function following prostate brachytherapy (PB) for localized PCa (3).
PURPOSE: Neutrophil-to-lymphocyte ratio (NLR), a marker for subclinical inflammation, has been previously shown to be associated with erectile dysfunction (ED). We studied the potential predictive value of the NLR on ED after prostate brachytherapy (PB) for PCa.
METHODS AND MATERIALS: Between July 2005 and January 2021, 842 patients were included in this retrospective study of a prospectively maintained database. ED was assessed using the Common Terminology Criteria for Adverse Events (CTCAE) physician-reported scale. ED was defined as a Grade 2 or 3 function. NLR count was determined 1–2 months before PB and separated into values PB <2 and ≥2. Patient characteristics and erectile function at last follow-up were compared for patients with a Univariate and multivariate analyses were performed to evaluate the predictive value of baseline NLR ≥2 on post-PB ED.
RESULTS: Baseline NLR ≥2 was found to be a statistically significant predictor of post-PB ED on both univariate (p = 0.002) and multivariate analyses (p = 0.008). Furthermore, the difference in ED prevalence between the NLR <2 and NLR ≥2 groups became more pronounced with longer follow-up after PB. The ED rate at 5 years post-PB was 43% for the NLR ≥2 groups, compared to 29% for the NLR <2 groups.
CONCLUSIONS: Subclinical systemic inflammation is a potentially important factor for predicting sexual toxicity after pelvic radiotherapy. NLR may be used as a proxy for predicting post-PB ED.
Neuropsychiatric Impact of Androgen Deprivation Therapy in Patients with Prostate Cancer: Current Evidence and Recommendations for the Clinician
2020, European Urology Focus
Citation Excerpt :
Large population-based cohort studies show no demonstrable increased risk of suicidality over cancer patients; however, cancer patients are at an increased risk of suicide [27,28]. PCa patients at the greatest risk of suicide were white, unmarried, and elderly, and had a longer time since diagnosis [30]. Higher levels of physical activity were protective against the affective impact of ADT [46–48].

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Review articleDecreasing suicide risk among patients with prostate cancer: Implications for depression, erectile dysfunction, and suicidal ideation screening

Highlights

Abstract

Objective

Materials and methods

Results

Conclusion

Introduction

Section snippets

Methods

Prostate cancer and suicide

Clinical implications

Conclusion

Urology

Eur Urol

Urol Oncol

Urology

Urol Oncol

Urol Oncol

Neuroscience

Eur J Cancer

Urology

J Urol

J Sex Med

Urology

J Urol

Am J Geriatr Psychiatry

Cancer statistics, 2017

CA Cancer J Clin

Patient-reported outcomes after monitoring, surgery, or radiotherapy for prostate cancer

N Engl J Med

Are cancer patients at higher suicide risk than the general population?

Scand J Public Health

Incidence of suicide in persons with cancer

J Clin Oncol

Factors associated with suicide in patients with genitourinary malignancies

Cancer

Review article
Decreasing suicide risk among patients with prostate cancer: Implications for depression, erectile dysfunction, and suicidal ideation screening