A cross-sectional study on associations of physical symptoms, health self-efficacy and suicidal ideation among Chinese hospitalized cancer patients following diagnosis.

doi:10.21203/rs.3.rs-21297/v2

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A cross-sectional study on associations of physical symptoms, health self-efficacy and suicidal ideation among Chinese hospitalized cancer patients following diagnosis.

https://doi.org/10.21203/rs.3.rs-21297/v2

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Background: Epidemiological studies have shown elevated suicide risk in cancer patients compare with the general population. This study was performed to examine the association between physical symptoms and suicidal ideation among Chinese hospitalized cancer patients and test the modifying effect of health self-efficacy on this association.

Methods: A cross-sectional study was conducted among 544 cancer patients from oncology settings in two general hospitals in northeast China via face-to-face interviews. Suicidal ideation was measured by using four items from the Yale Evaluation of Suicidality scale, dichotomized into a positive and negative score. Multivariable logistic regression was applied to examine the impact of physical symptoms, health self-efficacy and their interactions on suicidal ideation.

Results: We found a suicidal ideation rate of 26.3% in patients following cancer diagnosis. Logistic regression showed that insomnia (aOR=1.84, 95% CI 1.13 to 3.00, p =0.015), lack of appetite (aOR=2.14, 95% CI 1.26 to 3.64, p =0.005) were positively associated with suicidal ideation, low health self-efficacy showed a marginally significant exaggerating effect on the association between pain and suicidal ideation (aOR = 2.77, 95% CI 0.99 to 7.74, p =0.053), even after controlling for significant socio-demographic, clinical characteristics and depression.

Conclusions: These findings demonstrate the associations between insomnia、lack of appetite and suicidal ideation and highlight the potential moderating role of health self-efficacy in the identification and prevention of suicide among cancer patients.

Psychiatry

Suicidal ideation

Cancer

Physical symptoms

self-efficacy

Cancer is a major leading cause of death worldwide[1]. A cancer diagnosis and subsequent treatment can evoke psychological and physical distress in patients, complicate their life and even affect their will to live[2-4]. The suicide rate in cancer patients is estimated twice the rate in the general population[5, 6]. Prior suicidal ideation (SI) is the primary risk factor for future suicidal behaviors [7, 8]. 60% of first attempted suicide occurs within the first year of ideation onset [9]. Therefore, early detection of SI in cancer patients is critical for reducing the incidence of suicide and attempts.

Literature shows that up to 71% of cancer patients reported SI in clinical settings [10]. The possible risk factors leading to SI include female gender[11], old age[12], unmarried status[13, 14], retired[15], recurrence[2], metastases[2, 16], mental disorders[17] and pain[18-20]. Mental illnesses such as depressive disorders are known to be a significant predictor for SI[4, 15, 16]. However, there is difficult challenge for oncologists to diagnose depression because of the complexities involved in administering clinical interviews. Additionally, although SI is a core symptom of depression, and the two are strongly correlated, they are independent constructs[21]. Depression is not a necessary precondition for SI to occur. Patients can possess significant symptoms of depression or distress without meeting the strict criteria for diagnosable depression. If depression is under-diagnosed, it might be hard to find the pathway that leads to suicide. Physical complaints such as insomnia or appetite loss are commonly observed in patients with cancer[22], and are also diagnostic criteria for several mental disorders, including depressive disorders. We anticipate that some physical predictors will contribute to the presence of SI in both individuals with and without depressive disorders.

There is evidence that long-term effects of physical status are serious enough to result in suicidal thoughts in cancer patients[4, 18, 22-24]. A study on 48 patients with metastatic cancer found that physical symptom burden, more than pain and depression, correlated with desire for death[22]. However, the effects of physical status on SI have received relatively little attention compared with other psychiatric symptoms. Most studies analyzed association between numbers/sum-score of physical symptoms and SI or just focused on pain as the main risk factor [11, 18, 19, 25]. Only a Korean study investigate a set of physical symptoms associated with SI, i.e. diarrhea, hair loss, usual fatigue, in stomach cancer patients[23]. The analysis of specific symptoms offers opportunities to identify biomarkers for SI while summing symptoms may ignore important information[26]. It would be valuable to investigate specific symptoms associated with SI and improve early detection of the subsequent suicide risk in cancer patients.

Additionally, It is well known that expressions of depression maybe different across the cultures[27]. It has been reported that Asians express more physical symptoms than Westerners when experiencing depression, while the latter prone to express cognitive and psychological symptoms[27, 28]. Thus, the association between physical symptoms and SI may be different in an Asian country, e.g. China, than in western countries. However, there is a paucity of studies have examined this association in this group in China.

On the other hand, health self-efficacy, refer to individual’s coping ability and confidence in their ability to take care of their health in different circumstances[29, 30], is demonstrated plays critical role in pain management and health adjustment[31]. Previous study found that greater illness burden was significantly associated with lower health self-efficacy[32]. Moreover, emerging evidence has demonstrated that lower health self-efficacy increase the risk of suicide behavior across different time points from prior ideation to future intention[33, 34]. Therefore, health self-efficacy may play a moderating role in the associations between physical symptoms and SI. However, to the best of our knowledge, few studies have examined the potential moderating effects.

The present study aimed to examine the association between physical symptoms and SI in Chinese hospitalized patients with cancer, and the potential modifying effect of health self-efficacy on this association. We hypothesized 1) Physical symptoms would be associated with an increased risk for SI, even after controlling for established predictors. 2) The association between physical symptoms and SI would be greater for patients with low levels of health self-efficacy, compared to those with high levels.

Participants and procedure

This cross-sectional study was conducted in two general hospitals (the Second Affiliated Hospital of Dalian Medical University and the Zhongshan Affiliated Hospital of Dalian University) in Dalian, a typical Northeast coastal city of China, the gross domestic product (GDP) ranked 26th in China in 2018, a medium level of the country. Patients who were hospitalized in the oncology settings from the two hospitals were consecutively recruited during January to December 2015. Eligibility criteria included 1) diagnosed with cancer by pathology or cytology; 2) age of 18 years or older; 3) aware of their disease diagnosis; 4) provision of written informed consent. Exclusion criteria was 1) serious illness or cognitive impairment (such as dementia or delusions) or too weak to participate in the survey independently; 2) patients with language communication barriers or lack of capacity to cooperate the interview; 3) family caregivers required confidentiality of their diagnosis to the patients; Approval was obtained from the Committee on Human Ethics of Dalian Medical University. All enrolled patients signed a written informed consent.

Trained research staff conducted the interview after he/she had been undergoing treatment at least three days because we asked physical symptoms in the previous two days. All the patients were interviewed face-to-face lasted 40-50 minutes. All the measures were verbally administered to enhance data accuracy and reduce the frequency of missing data. As for cancer relevant information, such as type of cancer, stage at diagnosis, medical treatment, and metastatic status were withdrawn from the patients’ medical records.

Measures

Suicidal ideation: The YES scale is a 16-item structured questionnaire that assess current suicidal thoughts and actions, history of suicide attempts and feelings/attitudes on suicide[35]. It has demonstrated adequate validity in cancer patients [3,35]. ( see Additional file 1: Appendix 1). The first four items are a screening measure that assesses the strength of the patients’ wish to live and wish to die (passive SI), whether the patient has thoughts of killing himself/herself (active SI), and whether the patient feels dying outweighs living. Because of the rarity with which any suicidality was endorsed, these screening items were used to assess suicidal ideation in this study (Cronbach'sα=0.93). Patients’ scores were dichotomized where positive screen (endorsement of any item)=1 and negative screen = 0, because we wanted to detect clear and potential suicidal thoughts. These questions on SI are also used in many previous studies.

Independent variables and covariates

Physical symptoms were measured with one-item from the McGill Quality of Life Questionnaire (MQOL)[36]. Participants were asked whether have these symptoms over the previous two days with a response of yes and no. 14 items were included: pain, shortness of breath, insomnia, weakness, fatigue, nausea, lack of appetite, constipation, diarrhea, edema, cough, vomiting, fever and bloated.

Health self-efficacy: We measured health self-efficacy by using the Chinese version of the Strategies Used by People to Promote Health (SUPPH)[37]. This scale is a 29-item validated scale including three dimensions. Each item is rated on a five-point scale ranging from “little confidence” (1) to “ quite a lot of confidence” (5). All the items were summed into a score. Higher score indicates a higher sense of health self-efficacy. To evaluate the relative risk of SI, the scores were categorized into high (≥50) and low groups (<50) by the median. The Cronbach'sαof the current data was 0.96.

Depression: Clinician diagnosis of depression was evaluated by the 17-item version of the Hamilton Depression Rating Scale (HDRS-17)[38], which assess the severity of depression symptoms over the past week. It contains 17 items to detect depressive disorder and identify severity classification by semi-structured interview. A higher total score indicates a greater severity of depression. Severity classifications were defined as follows: 0–7 for no depression, 8–16 for mild depression, 17–23 for moderate depression, and ≥24 for severe depression. According to the proposal of Zimmerman et al[39], the cut-off value was 8 for identifying depressive disorder in our study. Reliability was good in the present study (Cronbach’sα=0.84; Split reliability=0.79).

Other variables: Socio-demographic characteristics included sex, age, marital status, education, residence, employment status, household income, smoking habit and drinking habit. Clinical related variables included site of cancer, stage at diagnosis, medical treatment, time since diagnosis and metastasis status.

Statistical analysis

Descriptive analyses, chi-square were used to compare the differences in socio-demographics and clinical associations between those who with and without suicidal ideation. Multivariate logistic regression models were performed to evaluate the independent association of physical symptoms with SI and test the interaction item of physical symptoms and health self-efficacy. The ratios were adjusted for potential confounding factors to SI, including demographic and clinical-related characteristics and diagnosed depression. All statistical analyses were conducted by using IBM SPSS version 21.0. The reported CIs were calculated at the 95% and statistical significance was set at .05 level, all tests were two-sided.

Sample characteristics

A total of 700 cancer patients were invited to participate in this survey. Among them, 69 could not cooperate due to poor physical or mental health or low education level. 59 could cooperate objectively, but refused to join. 282 out of 350 hospitalized patients from Zhongshan Affiliated hospital of Dalian University (response rate 80.6%), and 290 out of 350 inpatients from Second hospital of Dalian Medical University (response rate 82.9%) agree to join our study. 28 patients failed to complete the questionnaire and exited in the halfway. Finally, a total of 544 patients were included in the analysis (valid rate 95.1%), sample characteristics are shown in Table 1. Approximately half of the sample was females 51.8%, 49.8% from Zhongshan Affiliated hospital, with a mean age of 59.9 years [standard deviation (SD)=11.6], ranging from 19 to 81 years old. 78.3% primarily lived in the city. Overall, the majority sample was composed of three types of cancer: digestive system cancer (29%), lung cancer (23.7%) and breast cancer (18.9%). Almost half of the patients were present metastasis, diagnosed with cancer more than 1 year (Table 1). The percentage of missing data was less than 1.5% for all relevant variables and missing data on all variables except for SI was assumed to be in the low-risk category.

Prevalence of suicidal ideation

Out of the total patients (n=544), over one-forth of them reported that they have experienced SI since cancer diagnosis. The prevalence of SI was 26.3% (n=143), with 24.4% in man and 28.0% in woman.

Study factors associated with suicidal ideation

Table 2 displays a comparison of socio-demographic and clinical related characteristics between patients with and without SI. Compared to patients without SI, we found that no significant difference of most demographic variables, including sex, age, education attainment or household income between the two groups (all p>0.05), but significantly difference in marital status, employment status, metastasis, currently diagnosed depression. Although stage at diagnosis was not significant, p value was marginal. In addition, positive significant differences were shown in physical symptoms (pain, short of breath, insomnia, nausea and lack of appetite) and low health self-efficacy. Based on these results we entered socio-demographic factors, metastasis, stage at diagnosis and depression as control variables in the subsequent analysis.

Multivariate logistic regression analysis was conducted to examine the effect of physical symptoms on SI. In model 3 (table 3), There is a positive association between SI and symptoms of insomnia (aOR=1.84, 95% CI 1.13 to 3.00, p =0.015) and lack of appetite (aOR=2.14, 95% CI 1.26 to 3.64, p =0.005), after adjusting for socio-demographic, clinical variables and diagnosed depression.

In table 4, physical symptoms of insomnia and lack of appetite were significantly associated with SI in patients with low levels of health self-efficacy. According to a difference in OR between high and low health self-efficacy, Two-way interaction terms of health self-efficacy×each physical symptom were entered and tested individually. In model 3, low health self-efficacy showed a marginally significant exaggerating effect on the association between pain and suicidal ideation (aOR = 2.77, 95% CI 0.99 to 7.74, p =0.053), adjusted for all the confounding variables.

As the HDRS-17 contains items about sleep, weight loss and suicide, the analysis was repeated conducted excluding those items (HDRS-12 items scores), which as the controlling variables. Results did not differ significantly. Insomnia (aOR=2.04, 95% CI 1.19 to 3.50, p =0.009) and lack of appetite (aOR=2.35, 95% CI 1.30 to 4.23, p =0.0005), low health self-efficacy (aOR=2.68, 95% CI 0.96 to 7.47, p =0.0005), respectively. (Additional file 2: Appendix model 3 in table 3 & table 4)

Overall, our study revealed that the prevalence of post-diagnosis SI was 26.3% among Chinese hospitalized cancer patients. Patients with symptoms of insomnia or lack of appetite were at higher likelihood of reporting SI, even after adjusting for socio-demographic variables (marital status, being retired), clinical variables (stage at diagnosis, metastasis) and diagnosed depression. Furthermore, our findings suggest a marginally exaggerating effect of low health self-efficacy on pain and SI, after adjusted for all the confounding variables.

In the current study, 26.3% of the hospitalized patients reported SI following cancer diagnosis, which was higher than the previous reports (15.3-18.4%) in Chinese cancer population [25, 40, 41]. and it was also higher than that in some Western studies (7.8-17.7%)[14, 17-20], but much lower than that in Japan and Korea (34.7-71%)[23, 42-44].Our data was comparable to those of previous researches in Spain, the United States and Taiwan (22.6-29.5)[4, 13, 15]. The prevalence of SI varies from different studies based on different sample and measures. The majority of the sample were cancer patients of the digestive system and lung cancer, and those diagnosed with stage III and IV accounted for 70% of the total sample. Previous studies indicated cancer site and stage at diagnosis were associated factors for SI[14, 44]. Moreover, the scale utilized in our study included passive and active SI as the outcome, the passive SI referred to the death ideation as a wish to die or would be better off dead, the active SI refers to thoughts of killing oneself[45], which can elevated the prevalence.

To our best knowledge, this is the first study to examine the associations of physical symptoms, health self-efficacy and SI, and their interactions on SI among cancer patients. In line with our hypothesis, we found that patients with specific physical symptoms were more likely to report SI. Lack of appetite was about two times associated with the odds of SI after adjusted for socio-demographic and clinical characteristics. Choi et al. found physical symptoms were significantly associated with SI in stomach cancer population[23]. Prior studies demonstrated that patients with difficulties in vital function, such as eating, experience more helplessness/hopelessness and were therefore at higher risk of SI[24, 44]. The observed relationship between insomnia and SI is biologically plausible. Sleeping loss can cause various endocrine and immunological changes, prior studies have proved that dysfunction of the serotonin (5-hydroxytriptamine) plays a significant role in suicide[46]. Besides, insufficient sleep may negatively impact cognitive function resulting in poor judgment, deficits in impulse control, which might contribute to SI and behaviors.[47]. Moreover, insomnia as a diagnostic criterion of depression and also strongly associated with co-occurring mental disorders[48], which in turn are associated with increased risk for suicidality.

In consistent with our second hypothesis, our study suggested that low health self-efficacy played a marginally significant exaggerating effect on the association between pain and SI. Studies have found that patients with comparable levels of pain tend to have less depressive symptoms if they have higher health self-efficacy[49]. Health self-efficacy reflects individual’s perceived ability to cope with stress and confidence in overcoming challenges to their health[29, 30]. Prior evidence showed that cancer patients perceived higher health self-efficacy reported lower psychological distress levels and higher quality of life[31]. In contrast, as a result of low self-efficacy, individuals may prematurely terminate their coping efforts and instead consider how to escape the distressing situation and think of suicide.

There are some limitations in our study. First, our sample were recruited in cancer departments from two general hospitals in northeast China, thus the results may limit generalization to the cancer-specialized hospitals or the outpatients settings. Second, respondents may have not reported SI due to stigma or embarrassment related to suicide behaviors, the prevalence of SI reported in our study might be an underestimation. Third, patients who refused or did not complete this interview may experience severe physical adverse effects or emotional distress, which may product a selection bias, and we did not compare the demographic differences between participants who completed the survey and those who did not. Fourth, the physical symptoms assessed in the past two days, which might include occasional symptoms and might not occur simultaneously with SI seems to be a serious limitation of this study. Fifth, the variable of depressive symptoms was based on HRSD-17 scores, we may lose some information by using a cutoff score to dichotomize the variable of diagnosed depression instead of using continuous HRSD-17 scores. In addition, for the HRSD scale contains items on SI, insomnia and weight loss, we repeated adjusted the confounder of depressive symptoms severity based on HRSD-17 total scores and HRSD-12 scores without SI, sleep and weight items (see Additional 2-Appendix table3-4). Sixth, apart from depression disorders, we did not identify other mental disorders in analyzing the predictors. Finally, owing to the cross-sectional study, no direct causal relationship can be made. longitudinal research is needed on health self-efficacy interventions in reducing suicidal thoughts and further risks of suicide, such as future intent or prior suicide attempts.

One in four cancer patients undergoing treatment reported SI after diagnosis, indicates that the high-risk on suicidality remains an issue for this population in China. There are several clinical implications. First, to prevent suicide in cancer patients, we suggest that clinicians pay attention to patients’ physical symptoms, especially insomnia and lack of appetite, which may lead to SI directly. Second, Provide cognitive behavioral therapy and skills to manage physical symptoms for the patients may yield meaningful results. Third, improvement in the sense of health self-efficacy in those with low health self-efficacy patients are essential for hospital suicide prevention, especially in cancer patients with pain. We believe we can identify physical indicators and provide long-term screening and psychological treatment to ameliorate the risk of suicide in cancer patients.

In summary, the current study observed significant associations between insomnia, lack of appetite and SI. Furthermore, health self-efficacy showed moderating role on pain and SI among Chinese hospitalized patients with cancer. Paying attention to these physical symptoms and promoting the sense of health self-efficacy could be useful for oncology professionals to detect high-risk patients early and enable timely interventions.

AOR: Adjusted odds ratio; CI: Confidence intervals; SI: Suicidal ideation; YES: Yale Evaluation of Suicidality; MQOL: McGill Quality of Life Questionnaire; SUPPH: Strategies Used by People to Promote Health; HDRS: Hamilton Depression Rating Scale; SE: Self-efficacy

Ethics approval and consent to participate

This study received ethical approval from the Committee on Human Ethics of Dalian Medical University and all research processes met ethical standards (No. 2019-11). Written informed content was obtained from the patients prior to the survey.

Consent for publication

Not applicable.

Availability of data and materials

Data can be gained from the corresponding author.

Competing interests

The authors declare that they have no competing interests.

Funding

No funding was solicited or received for this manuscript.

Authors’ contributions

QX wrote the manuscript as a first author. Professor CJ conceived and designed the study as a corresponding author. Professor NK, SJ and LL contributed to the interpretation of the analysis results and revised the manuscript. Professor NK and MF gave critical comments to this manuscript. Clinical oncology staff was involved in the collection of the data. All authors have read and approved the manuscript.

Acknowledgements

We are grateful to all the medical staffs and patients in our study and to those who contributed to the clinical evaluation of the subjects.

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A cross-sectional study on associations of physical symptoms, health self-efficacy and suicidal ideation among Chinese hospitalized cancer patients following diagnosis.

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