Distress and Factors Associated with Suicidal Ideation in Veterans Living with Cancer
Backgrounds and Objectives: Eliminating veteran suicide is a top priority for the US Department of Veterans Affairs (VA). Veterans with cancer may be at particular risk for suicidal ideation (SI). The current study aimed to understand factors associated with distress in veterans with cancer who were referred for psychology services, and identify problems associated with SI.
Methods: Health records of veterans with cancer (N = 174) were reviewed to abstract data, including results of National Comprehensive Cancer Network (NCCN) Distress Thermometer and Problems List and clinical suicide risk assessments.
Results: Veterans with severe distress were significantly more likely to endorse SI and have a history of suicide attempt(s) when compared with veterans with mild or moderate distress ( χ 2 = 18.36, P < .001). Of the problems endorsed on the NCCN Problems List, family problems were most strongly linked to SI ( χ 2 = 5.54, degrees of freedom [ df ] = 1, P = .02). Specifically, veterans who endorsed problems with their partner were 5 times more likely to experience SI when compared with veterans who did not endorse this problem (Wald = 15.142; df = 1, P < .001).
Conclusions: This study is among the first to find partner problems as a suicide risk factor for veterans with cancer; and, underscore the importance of assessing for partner problems and suicidal ideation among veterans with cancer. This study supports the VA mission to end veteran suicide and addresses a gap in current literature by investigating the understudied population of veterans living with cancer and risk factors for SI.
Results
The sample consisted of 174 veterans (Table 1). The majority (77.6%) were male with a mean age of nearly 62 years (range, 29-87). Most identified as white (74.1%) with half reporting they were either married or living with a partner.
Prostate cancer (19.0%) was the most common type of cancer among study participants followed by head and neck (18.4%), lymphoma/leukemia (11.5%), lung (11.5%), and breast (10.9%); 31.6% had metastatic disease and 14.9% had recurrent disease. Chemotherapy (42.5%) was the most common treatment modality, followed by surgery (38.5%) and radiation (31.6%). The sample was distributed among the 3 distress DT categories: mild (18.4%), moderate (42.5%), and severe (39.1%).
Problems Endorsed
Treatment decisions (44.3%) and insurance/financial concerns (35.1%) were the most frequently endorsed practical problems (Figure 1). Family health issues (33.9%) and dealing with partner (23.0%) were the most frequently endorsed family problems (Figure 2). Worry (73.0%) and depression (69.5%) were the most frequent emotional problems; of note, all emotional problems were endorsed by at least 50% of veterans (Figure 3). Fatigue (71.3%), sleep (70.7%), and pain (69%), were the most frequently endorsed physical problems (Figure 4). Spiritual/religious problems were endorsed by 15% of veterans.
Suicidal Ideation
Overall, 25.3% of veterans endorsed SI. About 20% of veterans reported a history of ≥ 1 suicide attempts in their lifetime. A significant relationship among distress categories and SI was found (χ2 = 18.36, P < .001). Veterans with severe distress were more likely to endorse SI (42.7%) when compared with veterans with mild (9.4%) or moderate (16.2%) distress.
Similarly, a significant relationship among distress categories and a history of a suicide attempt(s) was found (χ2 = 6.08, P = .048). Veterans with severe distress were more likely to have attempted suicide (29.4%) when compared with veterans with mild (12.5%) or moderate (14.9%) distress.
χ2 analyses were conducted to examine the relationships between DT problem domains and SI. A significant relationship was found between family problems and SI (
Logistic regression analyses determined whether items representative of the family problems domain were predictive of SI. Suicide attempt(s) were entered in the first step of the model to evaluate risk factors for SI over this already established risk factor. The assumptions of logistic regression were met.
The Hosmer-Lemeshow test (χ2 = 3.66, df = 5, P = .56) demonstrated that the model fit was good. The group of predictors used in the model differentiate between people who were experiencing SI and those who were not experiencing SI at the time of evaluation. A history of a suicide attempt(s) predicted SI, as expected (Wald = 6.821, df = 1, P = .01). The odds that a veteran with a history of a suicide attempt(s) would endorse SI at the time of the evaluation was nearly 3 times greater than that of veterans without a history of a suicide attempt(s). Over and above suicide attempts, problems dealing with partner (Wald = 15.142; df = 1, P < .001) was a second significant predictor of current SI. The odds that a veteran who endorsed problems dealing with partner would also endorse SI was > 5 times higher than that of veterans who did not endorse problems dealing with partner. This finding represents a significant risk factor for SI, over and above a history of a suicide attempt(s). The other items from the family problems domains were not significant (P > .05) (Table 3).
