Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 10  |  Issue : 3  |  Page : 281-283  

Suicide in a patient of rectal carcinoma: Exploration of psychodynamics from the suicide note


1 Department of Forensic Medicine and Toxicology, All India Institute of Medical Sciences, New Delhi, India
2 Department of Psychiatry, King George's Medical University, Lucknow, Uttar Pradesh, India

Date of Web Publication19-May-2017

Correspondence Address:
Sujita Kumar Kar
Department of Psychiatry, King George's Medical University, Lucknow - 226 003, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/MJDRDYPU.MJDRDYPU_287_16

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  Abstract 

Distress related with cancer not only impairs the quality of life and accelerates disease progression, but also causes noncancer mortality including suicide. The physical and psychological sufferings in a cancer patient are the major causes of suicide. Financial burden related to the expensive treatment of cancer further add up to the suffering of the patients as well as their family. We reported a case of rectal carcinoma, who committed suicide inside the hospital premises leaving behind a suicide note. Patient's clinical history, sociodemographic profile, and the suicide note were analyzed. The content analysis of the suicide note has been described along with an analysis of different factors associated with suicide in cancer patients in an Indian scenario. Suicide note may show the reflections of psychodynamics of suicide, hence, it needs to be included routinely during psychiatric evaluation.

Keywords: Cancer, psychodynamics, suicide, suicide note


How to cite this article:
Swain R, Pooniya S, Kar SK, Dhaka S. Suicide in a patient of rectal carcinoma: Exploration of psychodynamics from the suicide note. Med J DY Patil Univ 2017;10:281-3

How to cite this URL:
Swain R, Pooniya S, Kar SK, Dhaka S. Suicide in a patient of rectal carcinoma: Exploration of psychodynamics from the suicide note. Med J DY Patil Univ [serial online] 2017 [cited 2024 Mar 28];10:281-3. Available from: https://journals.lww.com/mjdy/pages/default.aspx/text.asp?2017/10/3/281/206588


  Introduction Top


Cancer is the second leading cause of death and disability worldwide and became one of the major causes of death in India.[1] To be diagnosed with cancer is one of the most traumatic events in patient's life and is subsequently associated with emotional disturbances especially depression and anxiety in later part of life.[2] Due to emotional disturbances, the suicide risk is increased in cancer patient in comparison to the general population.[3] The risk of suicide increases in the presence of risk factors such as recent diagnosis (within first 6 months) of cancer, cancer site with poor survival, diagnosis at an advanced stage, poor economic status, and presence of comorbid conditions.[4],[5],[6] Understanding the psychodynamics of suicide is of utmost importance before planning about its prevention. A better understanding of the psychodynamics of suicide will help in strengthening the suicide prevention program.


  Case Report Top


A 20-year-old male had presented to the surgery outpatient department with complaints of increased frequency of stool, incomplete evacuation of bowel with bleeding per rectum in the year 2013. On per rectal examination, a growth involving anal canal, 2 cm above the anal verge was present. A punched biopsy and computed tomography scan of the abdomen was done for diagnosis and staging of the disease. After that, it was diagnosed as a case of adenocarcinoma of rectum in Stage IIIC (T3N2bMO). The growth was surgically resected, and since then he was under chemotherapy on day care basis. On the day of the incident, he came to the hospital for follow-up and for receiving a further dose of chemotherapy. He was found hanging with the help of a nylon rope inside the bathroom of hospital ward. The body was immediately taken to the emergency department where he was declared brought dead and sent to the department of forensic medicine for autopsy. A handwritten suicide note was recovered from the crime scene, on which he had expressed his concern about the illness, his pain and sufferings, financial constraints as well as the impact of his illness on the burden of care of his caregivers (family members). In one place, he had mentioned that – “All doors have been closed for me.” To this, he explained as the reason for committing suicide. In his suicide note, he had also mentioned about his willingness for organ donation after death.

As per the available information, there was no history of psychiatric illness in the patient. His family members never reported about any persistent change of behavior (other than his concern for illness and expenses for treatment). His mental status before the commission of suicide was not possible; hence, the psychological analysis was made on the basis of suicide note analysis.

Suicide note analysis

In the handwritten suicide note, he had expressed his feelings of hopelessness which was also emphasized in several other places of suicide note. To this, he explained as the reason for committing suicide. His willingness for organ donation indicates to an altruistic defense to get rid of distress related to suicide.


  Discussion Top


Cancer diagnosis is a major stressor in the life of any patient, which attributes to considerable physical and psychological distress [5] and may be associated with increased risk of suicide. Previous studies in diverse populations suggested that suicide is approximately twice as prevalent among cancer patients as compared to the general population.[3],[7],[8],[9] However, the suicide risk varies largely across countries and regions. Several studies have reported risk factors associated with suicide in cancer patients which include the anatomical site of cancer, staging, period shortly after cancer diagnosis, and demographic profile such as old age, male, low education, and unemployment.[4],[5],[6],[7],[10],[11],[12] Studies have reported that suicide risk is highest during the 1st year after cancer diagnosis and subsequently decreases with time.[7],[12],[13] Another study on suicide among cancer patients had revealed that suicidal risk was maximum during the first 12 weeks after diagnosis, with highest relative risk observed for carcinoma esophagus, liver or pancreas followed by lung cancer but the authors did not consider the cancer stage at diagnosis during the study.[13] Our case was of a 20-year-old male with adenocarcinoma of rectum in stage IIIC (T3N2bMO) undergoing postoperative chemotherapy. He had committed suicide after 2 years of diagnosis of cancer. Suicidal risk was increased in all age groups with a tendency to less excess risk in patients aged more than 80 years, and excess risk was also attributable to male cancer patient.[6] Suicide is the most serious sequel of mental illnesses. In this index patient, though psychiatric evaluation was not possible before suicide, however considering the content of suicide note, nature of medical illness, and financial constraints, possible diagnoses such as – major depressive disorder or adjustment disorder may be considered. An underlying personality related problem also could not be ruled out. In the presence of severe medical illnesses, it is often challenging to diagnose depression as many of the symptoms (e.g., loss of appetite, loss of weight, disturbance of sleep, low mood, and lack of energy) can be explainable due to the medical illness.

Such types of studies regarding the assessment of different risk factors which are attributable to suicide in cancer patients are lacking in the Indian scenario. In developing countries like India, most cases of the cancer were diagnosed in the advanced stage and head and neck cancer being the most common. In the above two conditions, the suicide risk is high. A majority of the patients (76%) faced financial problems while undergoing treatment in India [1] which could be a risk factor for suicide as seen in our case. There is huge difference in cost of treatment in government and private hospital in India. The main reason of high cost is due to high cost imported equipment for setting up a cancer hospital and expensive chemotherapeutic drugs.[14] A study revealed that there is not much difference between costs in the treatment of stage 1 and stage 2 oral cancer but cost has risen significantly for stage 3 patient.[15] Cancer treatment puts a family under financial constraints and may affect the routine functioning as well as the productivity of an individual. Due to cancer, individuals face difficulty in meeting the social expectations which may lead to failure of social regulation. Durkheim had explained about role of social integration and social regulation in determining the suicidal behavior.[16],[17] Failure or poor social integration and regulation is a major reason for increasing suicide, however, suicide is also rarely results from excessive social integration and regulation.[18] In our patient, there was a loss of social regulation (failure to meet the needs and regulate the emotions guided by social norms), whereas there was high social integration (excessive concern for family members due to strong emotional connectedness) which attributed to his egoistic and altruistic suicidal behavior. Being diagnosed with cancer is stressful, subsequently receiving treatment for cancer, which is a costly affair, adds to the burden of stress. Disability due to cancer and anticancer drug-related side effects are adding to the distress. All the above factors might have played crucial role in the development of suicidal behavior in our patient.

India has maximum number of suicide-related death in the world, hence considered as the suicide capital of the world.[16] Hence, understanding the psychodynamics of suicide and utilizing the knowledge in prevention of suicide is the need of the hour. A suicide note may help in understanding the psychodynamics of the suicide, hence to be analyzed from mental health perspective other than sociology point of view. As depression is commonly encountered in patients diagnosed with cancer, there is need of increasing awareness of general care physicians as well as oncologists about it. Mental health awareness will improve interdisciplinary liaisoning. A collaborative work with mental health professionals in the management of such patients will improve the clinical outcome as well as prevent suicide-related mortality. As suicide is preventable, efforts should be taken to identify the risk factors of suicide and appropriate intervention need to be done to prevent it. Clinicians should routinely evaluate the mental status as well as suicidal risk in cancer patients during diagnosis and treatment of cancer. Breaking the bad news (detection of cancer) to the patient need to be done cautiously in an empathetic way as it may have a significant impact on the mental wellbeing of the patient. The mental health professionals need to focus on installation of hope, strengthening the family support and supportive psychotherapy. An appropriate antidepressant needs to be chosen considering their potential interaction with ongoing anticancer treatment. Psychological interventions in cancer patients are expected to improve their quality of life and distress. Understanding the client specific needs and addressing them may reduce the distress of the clients and their family. Patients and their caregivers need to be made aware of various government schemes related to health, approaching appropriate health facilities for treatment at free of cost or minimal cost. Providing psychosocial support to the client and their family by counselors and referring them to mental health professionals may facilitate timely intervention.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
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Kendal WS, Kendal WM. Comparative risk factors for accidental and suicidal death in cancer patients. Crisis 2012;33:325-34.  Back to cited text no. 11
    
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Ahn MH, Park S, Lee HB, Ramsey CM, Na R, Kim SO, et al. Suicide in cancer patients within the first year of diagnosis. Psychooncology 2015;24:601-7.  Back to cited text no. 12
    
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Fang F, Fall K, Mittleman MA, Sparén P, Ye W, Adami HO, et al. Suicide and cardiovascular death after a cancer diagnosis. N Engl J Med 2012;366:1310-8.  Back to cited text no. 13
    
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Sharma EK. Killer Cost. Business Today; 2013. Available from: http://www.businesstoday.intoday.in/story/cancer-treatment- cost/1/191785.html. [Last accessed on 2015 Apr 02].  Back to cited text no. 14
    
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Goyal S. Cost of Oral Cancer in a Super-speciality Private Hospital in Delhi. National Institute of Health and Family Welfare, New Delhi; 2013. [Unpublished M.D. Thesis].  Back to cited text no. 15
    
16.
Durkheim É. Le suicide [suicide]. Paris: Felix Alcan. 1897.  Back to cited text no. 16
    
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Lester D. Suicide and culture. World Cult Psychiatry Res Rev 2008;3:51-68.  Back to cited text no. 17
    
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Patel V, Ramasundarahettige C, Vijayakumar L, Thakur JS, Gajalakshmi V, Gururaj G, et al. Suicide mortality in India: A nationally representative survey. Lancet 2012;379:2343-51.  Back to cited text no. 18
    



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