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Medical Illness, Suicide, and Assisted Death

Abstract and Keywords

Because of their focus on psychopathology, mental health clinicians may overlook the potential significance of medical illness as a risk factor for suicide. In this chapter, the author presents evidence that physical illness, particularly certain physical illnesses, can be independent risk factors for suicide. In a number of these illnesses, depression is clearly a confounding risk factor, while in others the illness itself or its consequent functional impairments may lead to increased risk. When an individual has multiple physical illnesses, as often happens with the elderly, the cumulative burden can become overwhelming and heighten the risk of suicide. When physical illness becomes terminal, the competent patient has the right to refuse life-sustaining treatment. Whether that individual can receive assistance in dying has been more controversial. The chapter concludes with a presentation of data from a state where assisted suicide, also known as assisted death, has been legalized.

Keywords: suicide, suicide risk, suicide in medical illness, suicide in physical illness, suicide in terminal illness, burden of illness, assisted suicide, assisted death

It is practically axiomatic to state that there is a strong correlation between mental illness and the risk of suicide. Less attention, however, has been given to the fact that there may be an independent association between physical illness, particularly certain physical illnesses, and the risk of suicide (Druss & Pincus, 2000; Goodwin, Marusic, & Hoven, 2003; Harwood, Hawton, Hope, Harriss, & Jacoby, 2006; Ruzicka, Choi, & Sadkowsky, 2005).

In this chapter, I examine the existing data suggesting that medical or physical illness, and/or its effects, might be considered significant risk factors for suicide, independent of mental illness. I then discuss depression as a confounding risk factor for suicide in the medically ill. Next, I review particular medical illnesses and conditions from meta-analytic reviews and/or large register linkage studies that have been found to be associated with suicide. Finally, I discuss findings on the prevalence of suicide among individuals who are terminally ill, as well as data on assisted death (referred to by some as assisted suicide) in states such as Oregon, Washington, and Vermont, where it has been legalized.

Mental Illness and Medical Illness as Risk Factors for Suicide

Psychological autopsy studies (or retrospective studies of those who have committed suicide) have consistently found that approximately 90% or more of suicide victims (as per the official reports of coroners) have had a mental or emotional disorder (see, for example, Bertolote & Fleischmann, 2002; Beskow, 1979; Chynoweth, Tonge, & Armstrong, 1980; Rich, Young, & Fowler, 1986). On the other hand, Whitlock (1986) and Mackenzie and Popkin (1990) cumulatively reviewed more than 25 psychological autopsy studies, most of which had included 100 suicides or more, and found, respectively, that 34% and 43% of the suicides had a medical illness at the time of death. Moreover, in a psychological autopsy study undertaken in five counties in England, looking at 100 suicides within an elderly (p. 385) population (60 years of age or greater), Harwood, Hawton, Hope, Harriss, and Jacoby (2006) found that physical health problems were present in 82% of the sample, and they were thought to be contributory to suicide in 62% of the cases.

Although it seems clear that mental illness is more prevalent than physical illness among suicides, there is nonetheless evidence that physical illness may be a risk factor for suicidal behavior and suicide. Druss and Pincus (2000), in a large probability survey with an adolescent and young adult population (ages 17–39), collected information about lifetime suicidal ideation and suicide attempts as well as data on general medical conditions, depression, and alcohol use. They found that medical and mental illness each contributed independently to risk of suicidality. Greater risk of suicidal ideation, and particularly of suicide attempts, was conferred when an individual had more than one medical illness.

Using data from a national comorbidity study of late adolescents and adults (ages 15–54), Goodwin, Marusic, and Hoven (2003) examined associations between a self-report checklist of medical illnesses and responses to a question about lifetime suicide attempts. They found significantly increased odds of a suicide attempt with physical illness, even after controlling for demographic characteristics and mental disorders. They also found a linear, dose-response association between the total number of physical illnesses and the likelihood of a suicide attempt. In addition, Ruzicka, Choi, and Sadkowsky (2005), following the introduction of multiple-cause-of-death coding in Australia, reviewed all completed suicides over 5 years (1997–2001) and compared them with deaths by accident during that same period. Their findings confirmed the significant relationship of suicide with mental health problems, but they also found that certain physical diseases (most notably HIV and cancer) were significantly associated with suicide. In general, mental disorders were more prevalent than physical illnesses among suicide victims under age 60, while physical illnesses were more prevalent than mental disorders among suicide victims age 60 and over.

Further, Waern et al. (2002) and Conwell et al. (2010) did case-control studies to examine the association of suicide with medical and psychiatric illness. In both studies, the authors examined samples of individuals who had committed suicide (n = 85 and n = 86, respectively) with matched living community samples. In the study by Waern et al. (2002), the data for the suicide group were gathered from interviews with next-of-kin and by record review, while the data for the community sample were gathered directly by interview with control group participants. In the study by Conwell et al. (2010), the data for both groups were gathered from interviews with next-of-kin and by record review. The results in both studies supported previous findings of an association between psychiatric illness and suicide, and they both also found that physical illness was a significant, independent risk factor for suicide in the elderly. In the study by Conwell et al., it was also determined that the perception of deteriorating health and functional impairment were significant risk factors, with functional impairment being the more robust predictor of suicide.

Finally, Qin, Webb, Kapur, and Sorensen (2013) utilized a nested case-control design to study the association of hospitalization for physical illness, inpatient and outpatient treatment of psychiatric illness, and socioeconomic status in relation to suicide. They were able to use Danish national registers to detect 27,262 suicide cases during the period 1981–2006, and to select 468,007 live population controls from the national population of Denmark during that same time frame. Using conditional logistic regression to analyze the data, the investigators found that a history of physical illness significantly increased the risk of suicide and the effect was greater among women than men. They also noted a progressively increased risk of suicide associated with both the frequency of previous medical hospitalizations and the recency of the last hospitalization—the greater the number of hospitalizations or the more recent the last hospitalization, the higher the risk of suicide. When the data were adjusted for history of psychiatric illness, the associated risks were reduced to a certain extent, but the risk associated with physical illness remained highly elevated. They concluded that their robust findings supported a strong link between physical illness and risk of suicide in the general population. They also asserted that the progressive increase in suicide risk associated with frequency of hospitalization and multiple comorbidities indicated that the severity of physical illness was an important factor in the risk of subsequent suicide.

As Ruzicka et al. (2005) noted, the suicide risk associated with certain physical illnesses could well be mediated by secondary mood or affective symptoms; or, as suggested by Conwell et al. (2010), perceived health status or functional impairment might also mediate risk. In this regard, Kaplan, McFarland, Huguet, and Newsom (2007) reported on a study in (p. 386) which they examined physical illness and functional limitations as risk factors for suicide. They used data collected from a 1986 to 1994 National Health Interview Survey of 594,267 non-institutionalized people from 50 states and the District of Columbia and linked the data to the National Death Index. A Cox proportional hazard model showed that the respondents with functional limitations were at a higher risk for suicide relative to those without a functional limitation (HR = 2.78, 95% confidence interval [CI] = 1.42–5.43). The authors concluded that functional limitation appeared to be a much more powerful risk factor for suicide than physical illness. The findings suggest that clinicians should regard the burden of certain physical illnesses, or an accumulation of physical illnesses (possibly mediated by depression and/or functional limitation), as risk factors for suicide.

Depression as a Confounding Risk Factor for Suicide in People with Medical Illness

As noted earlier, many medical illnesses that have a heightened risk of suicide also have an associated heightened rate of depression. Webb et al. (2012) used the United Kingdom’s General Practice Research Database (GRPD; which includes virtually every resident of the UK) to investigate how the risk of suicide varies among different types of physical illness and to what degree depression explains the elevated risk. The GRPD was linked to the national mortality registration systems. For a case control study, the investigators drew 873 adult suicide cases and 17,460 living controls from approximately 4.7 million patient records during the period from January 1, 2001 to December 31, 2008. The 11 major conditions that they examined were cancer, coronary heart disease, hypertension, stroke, diabetes, asthma, chronic obstructive pulmonary disease, osteoarthritis, osteoporosis, back pain, and epilepsy. They found that, for women, there was an elevated risk of suicide for cancer and coronary heart disease that was independent of depression while, for men, there was an elevated risk of suicide for osteoporosis that was independent of depression. The risk for suicide in the other diseases and conditions was confounded by or attributable to depression.

We see in this study by Webb et al. that there are some physical illnesses that seem to have an independent association with suicide, while there may be many others in which associated depression accounts for the suicide risk. There is a large body of evidence that demonstrates that depression is highly comorbid with specific medical illnesses (Cassem, 1995; Harrington, 2002; Iosifescu, 2007). As Harrington (2002) has noted, depression is second only to hypertension as the most common diagnosis in primary care populations. Depression and medical comorbidity have been associated with high utilization of medical services, unexplained symptoms, increased functional disability, diminished quality of life, and increased morbidity and mortality (Harrington, 2002; Iosifescu, 2007).

As I mentioned at the beginning of this chapter, the great majority of completed suicides suffer from a major psychiatric disorder (Clark & Fawcett, 1992). Moreover, depression is the mental disorder most frequently associated with suicide. Thus, an estimated 50% of suicides suffer from depression at the time of death (Pokorny, 1983; Rich, Young, & Fowler, 1986). If serious medical illness is frequently associated with depression, it seems highly probable that there is a heightened risk of suicide among those with comorbid depression and physical illness.

Medical staff, however, often fail to detect depression in the medically ill, or they view it as appropriate to the patient’s condition (Berman & Pompili, 2011; Cassem, 1995; Harrington, 2002). Therefore, depression, an important risk factor for suicide, is frequently under-diagnosed and under-treated in the medically ill. Part of the problem may be that the diagnosis of depression in the medically ill is made difficult by the fact that the vegetative symptoms of depression (e.g., loss of appetite, decreased energy, loss of weight) may also be caused by the physical disease itself rather than by depression. Moreover, there is difficulty in distinguishing depression and demoralization (or the so-called giving up syndrome) in those with serious medical illness.

Just as the symptoms of depression can overlap with the symptoms of a particular medical disease, so too demoralization and depression can overlap, making the diagnosis of depression still more difficult. Nonetheless. given the current state of under-diagnosis and under-treatment of depression, Harrington (2002) has recommended having a relatively low threshold, or erring on the side of over-inclusion in the diagnosis and treatment of depression in the medically ill. His point is underscored when one considers the elevated risk of suicide in this population.

Specific Medical Illnesses Associated with Risk of Suicide

There are many medical illnesses and conditions. Most of them, as single diseases or injuries, appear (p. 387) to have little known risk of suicide (Berman & Pompili, 2011; Harris & Barraclough, 1994). As noted in Kleespies, Hough, and Romeo (2009), however, there are a few for which there is evidence of an associated risk of suicide. A number of these illnesses and conditions are considered neurological disorders (Arciniegas & Anderson, 2002).

Neurological Disorders

Many factors are thought to contribute to an increased risk of suicide in certain neurological disorders—associated depression, anxiety, cognitive impairment, pain, loss or decrease in function. In this section, I present the neurological disorders for which there is empirical evidence of a heightened risk of suicide. (For further information on neurobiological factors in suicide, see chapter 20 by Victoria Arango and Mark Underwood of this volume.)


It has long been recognized that there is a high incidence of depression among epileptic patients (Baker, 2006; Schmitz, 2005), and clinical observation has suggested that there is an elevated risk of suicide. Blumer, Wakhlu, Davies, and Hermann (1998), for example, warned that severe interictal dysphoric disorders may be associated with sudden suicide attempts during episodes of intense depressive mood.

A meta-analytic review of 29 studies involving over 50,000 patients with epilepsy seems to have confirmed that the risk of suicide is indeed heightened (Pompili, Girardi, Ruberto, & Tatarelli, 2005; Pompili, Girardi, & Tatarelli, 2006). In this review, most of the 29 cohorts indicated that suicide in patients with epilepsy was more frequent (and in some studies many times more frequent) than suicide in the general population. Only three of the cohorts had lower suicide rates than the general population.

In a case control study by Nilsson, Ahlbom, Farahmand, Asberg, and Tomson (2002), onset of epilepsy at an early age was found to be strongly associated with an increased risk of suicide. The relative risk was 16 times greater for onset at age 18 or younger compared to onset after age 29, and early onset of epilepsy has been associated with depression and perceived stigma.

In a seemingly paradoxical finding, a meta-analytic review of 11 studies of suicide after surgical treatment (to reduce seizure frequency) revealed that suicide in surgically treated epileptic patients was more frequent than suicide in the general population (Pompili, Girardi, Tatarelli, Angeletti, & Tatarelli, 2006). In a study by Blumer et al. (2002), which looked at over 10,000 patients treated at an epilepsy center in Memphis, five suicides were found, and all of them had a history of early onset (mean age 9.5 years) of long-standing complex partial seizures with very high seizure frequency. All of them committed suicide within a range of 3 months to 3 years after they had obtained full control of seizures for the first time either by temporal lobectomy (n = 3), by medication (n = 1), or by vagus nerve stimulation (n = 1). All of them also had a history of interictal dysphoria or depression. Antidepressant medications have been found to be very effective in treating the depression of chronic epilepsy and their use has been recommended in conjunction with the surgical treatment of epilepsy (Blumer et al., 1998).

Traumatic brain injury.

Studies have found a heightened risk of psychiatric disorders (e.g., major depression, panic disorder, obsessive-compulsive disorder, substance abuse), as well as an increased risk of suicidal ideation and suicide attempts, following a traumatic brain injury (Silver, Kramer, Greenwald, & Weissman, 2001; Simpson & Tate, 2005; Simpson & Tate, 2002). Although there were occasional patients in these samples who had a pre-injury suicide attempt, the vast majority of suicide attempts occurred post-injury. Moreover, in the study by Silver et al. (2001), the risk of suicide attempt remained elevated after adjusting for demographics and alcohol abuse.

Surprisingly, there has not been a great deal of research on completed suicide and traumatic brain injury (TBI), but there has been an excellent large register linkage study on this topic in Denmark. Teasdale and Engberg (2001b) selected patients on a national register of hospital admissions between 1979 and 1993 for three types of TBI: concussion (n = 126,114), cranial fracture (n = 7,560), and cerebral contusion or traumatic intracranial hemorrhage (n = 11,766). They then screened these patients in a national register of deaths for the same period. Standardized mortality ratios [SMR], stratified by sex and age, showed that the incidence of completed suicide was increased for all three groups relative to the general population (SMR = 3.0, 2.7, and 4.1, respectively). Further, regression analyses for proportional hazards showed a significantly greater risk of suicide among those with more serious brain injury, such as cerebral contusions or intracranial hemorrhages, relative to those with concussions or cranial fractures. Interestingly, there was also an increased rate of suicide among patients with only a concussion or with a cranial fracture with no known cerebral lesion.

(p. 388) The authors suggested that the greater suicide risk among the more serious cases might be attributed to concomitant risk factors, such as the development of psychiatric conditions or the physical, psychological, and social consequences of the injuries. The presence of a co-diagnosis of substance abuse was associated with increased suicide rates in all three diagnostic groups. Interestingly, the mortality rates were greater for females than for males, although the reverse is true in the general population.


Studies in Denmark and Finland have suggested that there is an elevated risk of suicide in patients who suffer a stroke. Stenager, Madsen, Stenager, and Boldsen (1998) did a linkage study with stroke patients in a single county of Denmark. They found that SMRs were markedly increased for suicide, particularly among relatively younger patients (<60 years of age), and among women. Likewise, Bronnum-Hansen, Davidsen, and Thorvalsen (2001) studied causes of death after a first stroke in Copenhagen County during the years 1982–1991. Although the major cause of death was cardiovascular disease, there were other causes of death with elevated risk including suicide.

Teasdale and Engberg (2001a) attempted to replicate the findings of Stenager et al. (1998) using a full national cohort of stroke patients in Denmark. Their sample consisted of 114,098 patients identified in the computerized National Bureau of Health’s Register of Hospitalization during the years 1979–1993. The overall annual incidence rate of suicide in the cohort was 83 out of 100,000 compared to an expected annual figure of 45 out of 100,000. Across all age groups, the SMR was 1.88 for men and 1.78 for women. SMRs were greatest (2.85) for patients under 50 years of age, and least (1.30) for patients 80 or older. Survival analysis suggested that suicide risk was greatest during the first 5 years after a stroke.

In a study by Forsstrom, Hakko, Nordstrom, Rasanen, and Mainio (2010) in the province of Oulu in northern Finland, researchers examined all suicides (N = 2283) that occurred during the years 1988–2007. They based the determination of death by suicide on death certificates from forensic medical-legal investigations. The diagnoses of the suicide victims were obtained from the Finnish Hospital Discharge Register. The investigators reported that 3.4% of the suicide victims (n = 75) had suffered from a stroke in their lifetime. Since depression is the most common psychiatric complication after a stroke, they also investigated whether the stroke victims in their sample had suffered from pre-stroke depression, post-stroke depression, or neither. They found that about 70% of the stroke victims with pre-stroke depression had committed suicide within a 2-year period after the stroke, while only 30% with no depression or post-stroke depression had done so within the same 2-year time frame. They concluded that a history of pre-stroke depression increased the risk of accelerated suicide among stroke victims, and they suggested that suicide risk be closely monitored with those exhibiting pre-stroke depression during the first 2 years following a stroke.

As Teasdale and Engberg (2001a) and Williams (2005) have pointed out, post-stroke depression is widely recognized. Forsstrom et al. (2010) caution clinicians to also attend to suicide risk when there is a history of pre-stroke depression. As with epilepsy and TBI, depression and other neuropsychiatric sequelae of stroke may be contributing to the heightened risk of suicide.

Multiple sclerosis.

According to meta-analytic studies done 20 years ago (Harris & Barraclough, 1994; Stenager & Stenager, 1992), patients with multiple sclerosis (MS) appeared to have a suicide rate that was twice that of the general population. In a more recent systematic review of suicide risk in MS individuals, Pompili et al. (2012) found six studies that confirmed an increased risk of suicide in MS patients and one that did not. Evidence from this review suggested that the suicide risk in MS patients was greater in males and that male patients with onset of MS before age 30 were at the highest risk. They also reported evidence that the risk was particularly high in the first year following diagnosis.

Large record linkage studies in Denmark and Sweden have been consistent with the preceding findings. Bronnum-Hansen, Stenager, Stenager, and Koch-Henriksen (2005) linked the Danish Multiple Sclerosis Registry, consisting of more than 10,000 patients, with the Cause of Death Registry for the period from 1953 to 1996. They found the standardized mortality ratio for suicide indicated the risk for patients with MS was more than twice that for the general population (SMR = 2.12). The increased risk was particularly high in the first year after diagnosis (SMR = 3.15), and the risk remained elevated (relative to the general population) more than 20 years after diagnosis.

In a study by Fredrikson, Cheng, Jiang, and Wasserman (2003), the 12,284 cases of MS in the Swedish Hospital Inpatient Register during the (p. 389) period 1969–1996 were linked with the Swedish Cause of Death Register. Suicide risk for patients with MS was again found to be more than twice that of the general population (SMR = 2.3). As in the Danish study, risk was particularly high in the first year after diagnosis. In this study, however, a gender difference was noted—the elevation in risk seemed greatest in young males but, for females, the risk was greatest in middle age (ages 30–59).

Studies have repeatedly found high rates of depression in patients with MS with the lifetime prevalence estimated in the range of 40%–60% (Caine & Schwid, 2002; Goldman Consensus Group, 2005; Siegert & Abernathy, 2005; Wallin, Wilken, Turner, Williams, & Kane, 2006; Williams et al., 2005). A number of factors may be involved in the increased incidence of depression—for example, the negative psychosocial effects of MS disability, the direct effect of lesions on brain structures that regulate mood, and the immune system dysfunction found in MS. It has also been suspected that depression and suicidality might be a side effect of some of the disease-modifying treatments (e.g., interferon-B) that have been used in the past decade to delay the progression of MS. Studies to date, however, have not provided clear evidence to support such a conclusion (Feinstein, 2000; Goeb et al., 2006; Patten & Metz, 2002).

Depression is the mental and emotional disorder with the highest associated rate of suicide, and it frequently goes undetected in patients with MS (Caine & Schwid, 2002; Goldman Consensus Group, 2005). Practitioners need to be alert to depression and potential suicide risk in patients with MS, and they need to treat it adequately. It should also be noted, however, that not all suicides among individuals with MS occur in the context of a depressive episode or disorder. Other factors, such as decreased quality of life, decreased ability to participate in meaningful activity, and loss of self-determination and control, have also been implicated (Williams et al., 2005).

Huntington’s disease.

Huntington’s disease (HD) is a disorder involving degeneration of nerve cells in the brain. There is progressive loss of mental function, including personality change, loss of cognitive ability, such as speech and judgment, and the development of neuropsychiatric symptoms (Paulsen, Ready, Hamilton, Mega, & Cummings, 2001). Abnormal facial and body movements are experienced, including rapid jerking movements. There is no known cure. As early as 1872, there was recognition of an association between mental illness and an increased risk for suicide with a diagnosis of HD (Huntington, 1872).

More recently, suicidal ideation was investigated in 4,171 individuals in the Huntington Study Group database (Paulsen, Hoth, Nehl, & Stierman, 2005). Similar to previous research, the findings highlighted elevated rates of depressive symptoms in individuals with Huntington’s disease. More than 40% of patients endorsed having current depressive symptoms and more than 10% had made a suicide attempt. These findings by Paulsen et al. (2005) and others (Robins Wahlin et al., 2000; Larsson, Luszcz, Bui, & Robins Wahlin, 2006) support the notion that there are two critical periods for increased risk of suicidal behavior in HD. The first critical period is just before receiving a formal diagnosis, and the second is in stage 2 of the disease, when independent functioning diminishes. Results showed that 19.8% of at-risk persons with soft neurological signs (i.e., non-specific motor abnormalities) had suicidal ideation while 23.5% of persons with possible HD (i.e., motor abnormalities that may be signs of HD but are not sufficient for a final diagnosis) had suicidal ideation. In persons who had been formally diagnosed with HD, 16.7% had suicidal ideation in stage 1, and 21.6% had suicidal ideation in stage 2 (Paulsen et al., 2005). The proportion of individuals with suicidal ideation diminished in stages 3, 4, and 5.

The occurrence of completed suicide in HD has been estimated to be four to five times that of the rate of the general population (Farrer, 1986). Di Maio et al. (1993) studied suicide risk in the families of 2,793 individuals who were registered with the National Huntington’s Disease Roster. Suicide rates were much higher than in the general population, based on 205 (7.3%) identified suicide events. Sorensen and Fenger (1992) reviewed the etiology of death among 395 Danish people with HD and among 282 of their unaffected siblings. They compared the findings with the suicide rate in the general Danish population. Suicide accounted for 5.6% of deaths among the individuals with HD, and 5.3% of deaths among their unaffected siblings. Both occurrences of suicide were significantly higher than the general Danish population rate of 2.7%. Not only is HD potentially demoralizing in itself, but the frequent co-occurrence of depression and other symptoms of mental disorder seem to heighten the risk of suicidal behavior and suicide.

A few studies have identified factors associated with increased risk of suicide in HD. A retrospective case-controlled study of instances of suicide in (p. 390) HD revealed that among a variety of clinical and social variables, the most important risk factor was having no children, with an odds ratio of 13.6 (Lipe, Schultz, & Bird, 1993). In a study by Almqvist, Bloch, Brinkman, Craufurd, and Hayden (1999), both employment status and psychiatric history within the 5 years leading up to testing were significantly related to the frequency of an adverse event following predictive testing for HD; and age, gender, and marital status did not influence the likelihood of an event. Further, in a recent prospective study of patients with prodromal HD, Fiedorowicz, Mills, Ruggle, Langbehn, and Paulsen (2011) found that a history of suicide attempts and the presence of depression were strongly predictive of suicidal behavior in these patients as compared with a control group.

Spinal cord injury/disorder.

People with spinal cord injury/disorder (SCI/D) are more vulnerable to certain life-threatening illnesses such as pneumonia, septicemia, cutaneous and bladder cancer, pulmonary emboli, and stroke. According to mortality studies of people with SCI in Japan and Australia (Imai, Kadowaki, & Aizawa, 2004; Soden et al., 2000), over the past two decades there has been a reduction in deaths due to these life-threatening illnesses. The result has apparently been an increased life expectancy that approaches 70% of normal for those with complete quadriplegia and 86% of normal for those with complete paraplegia.

There are some differences in the literature, however, in regard to the death rate by suicide among patients with SCI. In the relatively small Australian study by Soden et al. (2000), researchers found an SMR of 2.5 for suicide before 1980 and an SMR of 8.7 since then. This led to the suggestion that as the overall duration of survival had increased for SCI patients, the likelihood of suicide had also increased. Yet, in a larger study in the United States, Cao, Massaro, Krause, Chen, and Devivo (2014) linked the National Spinal Cord Injury Statistical Center database across three time periods (1973–1979, 1980–1989, and 1990–1999) to the National Death Index and the Social Security Death Index. Within the 31,339 SCI participants, 5,167 were found to be deceased at the end of the follow-up period and 198 of those had died by suicide. After controlling for age, sex, and race, they compared the SCI suicide rate to the suicide rate in the US general population and found the SMR for suicide to be 5.24 for the 1973–1979 SCI cohort, 3.65 for the 1980–1989 group, and 2.98 for 1990–1999. They interpreted these findings as indicating that there was a declining rate of suicide among individuals with SCI across this nearly 30-year period in the United States. Despite this decline, the authors pointed out that, in comparison to the general US population, all three SCI cohorts had higher rates of mortality due to suicide. They also identified three risk factors for suicide among individuals with SCI: (1) being non-Hispanic white; (2) being in the first 6 years of having an SCI; and (3) having thoracic 1 (T1) to sacral 3 (S3) injury levels with American Spinal Injury Association Impairment Scale ratings of A, B, or C.

Harris and Barraclough (1994) and Stenager and Stenager (1992) have pointed out that a heightened rate of mood disorders and substance abuse disorders in the SCI population may, in part, account for the heightened risk of suicide. Thus, alcohol or drug intoxication is often involved in the accidents that result in spinal cord injuries, and suicide attempts by those who are depressed and/or abusing substances are, at times, the cause of SCI. Estimates of the proportion of spinal cord injuries that result from suicide attempts have been modest—in the range of 1.5%–6.8% (Harris, Barraclough, Grundy, Bamford, & Inskip, 1996; Kennedy, Rogers, Speer, & Frankel, 1999; Pickett, Simpson, Walker, & Brison, 2003; Stanford, Soden, Bartrop, Mikk, & Taylor, 2007)—while Charlifue and Gerhart (1991) found that approximately 7% of patients with SCI who actually committed suicide had sustained their SCI in a prior suicide attempt.

Findings about a relationship between functional levels of impairment (e.g., complete quadriplegia, incomplete quadriplegia, complete paraplegia, and so on) and suicide risk have been inconsistent (see e.g., Hagen, Lie, Rekand, Gilhus, & Gronning, 2010; Hartkopp, Bronnum-Hansen, Seidenschnur, & Biering-Sorensen, 1998; Lidal et al., 2007; Soden et al., 2000). Suicide risk among SCI patients in general, however, appears to be greatest in the first 4–6 years after the injury (Cao et al., 2014; Charlifue & Gerhart, 1991; DeVivo, Black, Richards, & Sover, 1991). Thus, in a study of 5,200 individuals with SCI covering a 30-year period, Charlifue and Gerhart found that, of those who died by suicide, 50% did so within 3 years of onset of SCI and 76% within 4 years. These investigators also found several factors that distinguished individuals with SCI who committed suicide from matched non-suicidal people with SCI; these included (1) post-injury despondency, (2) experiences of shame, apathy, and helplessness, and (3) pre-injury family fragmentation.

(p. 391) Cancer

Large cohort studies that linked national cancer and death registries (totaling nearly 0.5 million to more than one million patients) have examined suicide risk in cancer patients. These studies, performed in Norway (Hem, Loge, Haldorsen, & Ekeberg, 2004), Sweden (Björkenstam, Edberg, Ayoubi, & Rosén, 2005), and Denmark (Yousaf, Christensen, Engholm, & Storm, 2005), found an elevated risk of suicide, similar to that reported by Harris and Barraclough (1994)—from 1.55 to 2.5 times greater than expected for males and from 1.35 to 2.9 for females. A multiple decade cohort study of one Japanese hospital also found similar results, despite a smaller sample size, with an overall increased suicide risk that was 1.8 times greater than expected at 5 years after cancer diagnosis (Tanaka et al., 1999).

In one of the first, if not the first, large cohort study in the United States comparing suicide rates of patients with cancer to the suicide rate of the general population, it was found that the incidence of suicide among more than 3.5 million patients diagnosed with cancer between 1973 and 2002 was nearly twice that of the general population (SMR = 1.88) (Misono, Weiss, Fann, Redman, & Yueh, 2008). As with the gender differences in the general population, the frequency of completed suicides for these female cancer patients was one-fifth that of the males, with a hazard ratio of 6.2 for male suicide relative to female suicide (Kendal, 2007).

Research has also pointed to an association between cancer-related suicide and age at diagnosis. In a case-control study of suicide risk associated with medical illness among New Jersey residents age 65 and older, cancer was the only medical condition that remained associated with suicide in adjusted analyses that accounted for psychiatric illness and the risk of dying within a year (Miller, Mogun, Azrael, Hempstead, & Solomon, 2008). In addition, Misono et al. (2008) documented higher rates of suicide with increasing age at cancer diagnosis among men. An examination of suicide rates by age at cancer diagnosis revealed that the highest SMR of 2.51 occurred for male and female patients in the uppermost age bracket of 85 years and older.

Three of the studies mentioned earlier reported that the increased risk of suicide was greatest within the first year of cancer diagnosis. Hem et al. (2004) noted an SMR of 3.09 for males and 2.18 for females within 5 months of diagnosis. The rate then dropped to 2.4 and 1.68, respectively, at 11 months post-diagnosis. Yousaf et al. (2005) found the increased risk for males was greatest within 3 months of diagnosis while for females it was at 3–12 months. Tanaka et al. (1999) found the greatest risk of suicide at 3–5 months following diagnosis. In the United States, Misono et al. (2008) reported the risk of suicide among patients with cancer greatest in the first 5 years after diagnosis. Although the risk declined after this, Misono and colleagues cautioned that it remained elevated compared with the general population for 15 years after diagnosis.

A number of studies have suggested that there is an elevated suicide risk associated with particular cancer sites, but these findings have been inconsistent. Harris and Barraclough (1994), for example, reported that suicides in individuals with head and neck cancers were nine times higher than expected in the general population and about four times higher than that of persons with other cancer diagnoses. More recent studies, however, have not offered strong confirmation of that finding, but have determined other sites to have an elevated risk of suicide. Hem et al. (2004) reported that the male relative risk of suicide was highest in cancer of the respiratory organs defined as the bronchus, trachea, and lung, with an SMR of 4.08, while Björkenstam et al. (2005) found the greatest rates in pancreatic cancer, followed by cancer of the esophagus, cancer of the lung, and cancer of the biliary passages and liver.

A more fruitful approach seems to be one in which there is an investigation of a possible association between suicide risk and prognosis and/or cancer stage at diagnosis. In a study by Dormer, McCaul, and Kristjanson (2008), specific types of cancer were grouped according to prognosis (5-year relative survival rates), and a very high SMR of 12.07 occurred for the poor prognosis group in the first 3 months after diagnosis. Similarly, Robinson, Renshaw, Okello, Moller, and Davies (2009) found that cancers with high fatality carried a higher risk of suicide in both men (SMR = 2.67) and women (SMR = 2.17) compared to those with low fatality. Several studies found suicide risk related to cancer stage at diagnosis. Rates of suicide have been noted to be higher for patients in the United States with advanced disease at diagnosis (Misono et al., 2008). For example, data indicate that risk of suicide is elevated for metastatic disease at diagnosis (Kendal, 2007), particularly for prostate cancer (Fang et al., 2010). Kendal (2007) also found that cancer-directed surgery that could not be carried out (p. 392) (for head and neck cancers), high-grade tumors, and treatment contraindications all were associated with elevated suicide risk. Examining suicide rates across various types of cancer, Robinson et al. (2009) reported a strong effect of advanced stage of disease in women.

These findings suggest that varying rates of suicide across cancer sites may be explained, at least in part, by variation in associated survival rates. It is notable that even when the likelihood of survival is high, cancer is still associated with increased suicide risk relative to the general population (Christensen, Yousaf, Engholm, & Storm, 2006).


When the HIV/AIDS epidemic was at its peak and there was no effective treatment, a diagnosis of HIV/AIDS was clearly associated with a heightened risk of suicide. In the often cited review of studies from 1966–1992, Harris and Barraclough (1994) estimated that the relative risk of suicide for men with HIV was seven times higher than the rate for men in the general population. By 1996, however, improved treatments, such as the highly active antiretroviral therapy (HAART) were introduced, raising the question of whether a more hopeful outlook for survival would lead to a decrease in the suicide rate among those with HIV/AIDS.

At least two studies initially suggested otherwise. In a study by Krentz, Kliewer, and Gill (2005) in southern Alberta, Canada, that linked patients with HIV/AIDS to cause-of-death data for the 20-year period of 1984–2003, deaths from AIDS-related causes decreased significantly, but deaths from non-AIDS-related causes, including suicide and drug overdose, increased across this time span. In a similar fashion, Lu et al. (2006) linked national HIV/AIDS registry data in Taiwan with cause of death and health insurance claims data for the period from 1994 to 2002. They also found that deaths from AIDS-related causes had decreased, but deaths from suicide had increased threefold during that time. Their conclusion was that as the duration of survival for patients with HIV/AIDS increased, the likelihood of suicide also increased. It was hypothesized that the prospect of lifelong HAART treatment with its discomforting side effects (including mood disorder) might lead patients to feel that longer life did not necessarily lead to better quality of life.

Recent studies, however, have been more consistent with the hypothesis that, with the introduction of HAART and increased life expectancy, the suicide rate has decreased for HIV/AIDS patients. Keiser et al. (2010) studied time trends and predictors of suicide in the pre-HAART era (1988–1995) and in the HAART era (1996–2008) in Switzerland. They linked patients from a national HIV cohort study of 15,275 individuals to a national mortality database and then calculated standardized mortality ratios that compare suicide in HIV-infected patients with suicide in the general population. In men, SMRs declined from 13.7 (95% Cl = 11.0–17.0) in the pre-HAART era to 3.5 (95% Cl = 2.5–4.8) in the HAART era; there was a similar decline with women, from 11.6 (95% Cl = 6.4–20.9) to 5.7 (95% Cl = 3.2–10.3).

Further, Rice, Smith, and Delpech (2010) investigated suicide among adults diagnosed with HIV in England, Wales, and Northern Ireland, from the beginning of the HAART era (1997) until well into it (2008). They examined causes of death as reported directly to the national HIV and AIDS new-diagnosis database, as well as in the annual census of people accessing HIV-related care. In addition to suicidal deaths, they included possible suicides (e.g., drug overdoses, carbon monoxide poisoning). As a result, they cautioned that their estimates of possible suicides may overestimate true suicides. Nonetheless, they found that the rate of possible suicides among adults accessing HIV-related services had decreased from 137.7 per 100,000 persons in 1997 to 31.6 per 100,000 in 2008, a seemingly clear decrease in suicides across the HAART era of treatment.

In a US study, Rockett, Wang, Lian, and Stack (2007) utilized the national Multiple Cause of Death files that contained information on both mental and physical health problems among those who had died by suicide in the years 1999–2003. The investigators had a comparison group of decedents whose underlying cause of death was unintentional injury. Unconditional logistic regression analyses revealed that three categories of comorbid psychopathology and one category of physical disease showed excess likelihood of being recorded on death certificates for suicides relative to death certificates for unintentional injuries. They were depression/mood disorders, schizophrenia, a residual nonorganic mental health category, and cancer. Given that, as mentioned earlier, HIV/AIDS had been found in the meta-analytic review by Harris and Barraclough (1994) to be clearly associated with an elevated rate of suicide, the authors commented on how it no longer seemed to have such an association. They felt that a plausible explanation of (p. 393) the difference was that, in the intervening years, the effective use of HAART had altered the mindset of those who tested positive for HIV.

Despite the fact that the studies cited in this section suggest that suicide risk, since the introduction of HAART, has decreased for patients with HIV/AIDS, Carrico (2010) has reminded us that the suicide rate among HIV positive persons remains significantly elevated relative to the general population. Clinicians need to continue to be cautious about the risk of suicide in this population.

End-Stage Renal Disease

According to Fabrazzo and De Santo (2006), depression is the most frequent psychiatric problem in patients with chronic renal disease. They link depression in end-stage renal disease (ESRD) patients to the many stressors that accompany the disease and its treatment. With renal dialysis, patients become dependent on the dialysis machine and the dialysis staff for life-sustaining treatment. They can become fearful of dying. The need to be dialyzed several times a week can lead to time constraints and functional limitations which, in turn, can lead to loss of employment, loss of income, and possibly a diminished role in the family. Sexual dysfunction in dialysis patients is not uncommon. The routine of being dialyzed may become tedious. Continuous ambulatory peritoneal dialysis, which can be performed at home, may reduce feelings of dependency, but it is not necessarily easy. The patient must observe a scrupulous antiseptic technique to avoid infections. Regardless of the dialysis technique, the patient needs to adhere to a low-phosphate, low-potassium, low-sodium, and restricted fluid intake diet. As noted by Levy (2000), these stressors can make the patient vulnerable to demoralization and/or depression. Such conditions can also be a breeding ground for suicidal thoughts and behavior.

In the past, ESRD patients were thought to have a very elevated rate of suicide. Bostwick and Cohen (2009), however, have contended that, by present-day standards, the past estimates of the suicide rate for ESRD patients may have been somewhat inflated. They base their argument on the fact that ethical thought about the rights of patients to refuse life-sustaining medical treatment (LSMT) has shifted markedly in the past 35–40 years in the direction of respecting the autonomous choices of the patient. They point out that in the past, the US health-care system was more paternalistic and likely to view an ESRD patient’s refusal of, or request to discontinue, renal dialysis as a suicidal act. Current medical ethics (e.g., Beauchamp and Childress, 2008), however, views the competent patient as having the right to refuse any LSMT, renal dialysis included, should they find it invasive and not in keeping with their wish to have personal control of what happens with their body. Death under these circumstances is not considered suicide.

Nonetheless, there appears to be a moderately elevated rate of suicide among ESRD patients in the United States. In a large register linkage study (Kurella, Kimmel, Young, & Chertow, 2005), 465,563 patients who initiated dialysis between 1995 and 2000 and who were registered in the United States Renal Data System (USRDS) were linked to the ESRD Death Notification Form register. The ESRD Death Notification Form makes a distinction between those who decide to withdraw from dialysis before death and those who commit suicide. Having made this distinction, the investigators nonetheless found a suicide incidence ratio of 1.84, indicating that the ESRD patients had a suicide rate that was 84% higher than the rate for the general population, even after accounting for demographic differences.

The rates of suicide among renal dialysis patients in the study by Kurella et al. (2005) tended to increase with age, with those 60 and over having the highest rates. There appears to be a somewhat different picture, however, with renal disease patients who received a kidney transplant. Ojo et al. (2000) took a sample of 86,502 kidney transplant patients who were registered with the United Network for Organ Sharing or with USRDS between 1988 and 1997 and linked them with cause-of-death information from a transplant recipient follow-up form and the ESRD Death Notification Form. They found an elevated rate of suicide for transplant patients (15.7 per 100,000 persons a year) relative to the general population rate (9 per 100,000 persons a year). Interestingly, 35% of the suicides occurred in the first 12 months after the transplant, and 16 months was the median time from transplantation to suicide. The mean age of the sample was 39 years, suggesting a higher risk of suicide at a younger age for transplant patients relative to the dialysis patients in the Kurella et al. study. The reasons for this apparent age difference are as yet undetermined.

Suicide and Assisted Death in Terminal Illness

Among medical illnesses, one might think that those illnesses that are in a terminal phase would be most likely to engender despair and hopelessness (p. 394) and, therefore, lead frequently to suicide. To the contrary, major psychological autopsy studies have suggested that a rather small percentage of suicide victims (approximately 2%–3%) had a terminal illness at the time of death (Clark & Horton-Deutsch, 1992). Some would argue that this estimate is low given that suicides among the terminally ill may be reported to the coroner as deaths caused by their physical illness (Quill, 1991). Jamison (1996), in fact, reported that he did an investigation of assisted suicides and found that the great majority of them (125 of 140) were recorded as deaths due to natural causes. Be this as it may, it seems unlikely that a large percentage of suicides have a terminal illness. As Joiner, Van Orden, Witte, & Rudd (2009) have noted, there is a basic instinct for self-preservation, and we naturally fight against annihilation, often even when hopelessly ill and clearly dying. That is partly why suicide is a low base rate event and often accompanied by great ambivalence.

As discussed in the previous section on end-stage renal disease, present-day medical ethics in the United States supports the right of the competent terminally ill patient to refuse life-sustaining treatment, opt for comfort care only, and let the disease run its course. More controversial, however, is the practice of assisted suicide or assisted death in which a physician assists a competent, terminally ill patient in dying (if requested voluntarily) by providing a prescription for medication to be used with the primary intention of ending his or her own life.1 A patient is considered terminally ill if he or she has an incurable condition with unacceptable suffering, and his or her condition is expected to cause death in the next 6 months. Physician-assisted death is currently legal in four states—Oregon, Washington, and Vermont through legislation, and in Montana by a court decision. It is also legal in one county of New Mexico through a court decision.

Perhaps the most reliable information on assisted death or assisted suicide with the terminally ill can be found in the data kept by the state of Oregon, the first state to approve physician-assisted death.2 The Oregon Death with Dignity Act (ODDA) has been in effect since 1998 (Oregon Health Authority—Public Health Division, 2014). There were 752 individuals who used the law to hasten death through 2013. Of those, 97.3% were white, 1.1% were Asian American, 0.7% were Hispanic American, and 0.1% were African American. A few more men (52.7%) than women (47.3%) used the Act. The median age was 71 with an age range of 25–96. Fifty-six percent were in the age range of 65–84. Of those who used the ODDA, 46.2% were married, 22.6% divorced, 22.8% widowed, and 8.4% never married. Those who exercised their right under the law tended to be more highly educated (45.6% had baccalaureate degrees or higher).

Participants have been most likely to have cancer (78.9%), and cancer of the lung and of the bronchus were the most frequent locations (18.6% of those with cancer). Another 7.6% of the cancer patients had breast cancer and 6.5% pancreatic cancer. Amyotrophic lateral sclerosis (ALS) was the diagnosis in 7.2% of participants, 4.5% had chronic lower respiratory disease, 1.9% had heart disease, and 1.2% HIV/AIDS. Ninety-five percent of the patients died at home with 90.1% of them enrolled in hospice. Only 1.7% did not have health insurance. The median duration of their patient-physician relationship was 12 weeks.

The most frequently mentioned end-of-life concerns were loss of autonomy (91.4%), decreasing ability to participate in activities that made life enjoyable (88.9%), loss of dignity (80.9%), and loss of the control of bodily functions (50.3%). Only 23.7% mentioned inadequate pain control or concern about that. Under the ODDA, if the patient’s judgment is considered impaired by a psychiatric or psychological disorder, the patient must be referred for a psychological examination. Only 5.9% of patients were referred for a psychiatric or psychological evaluation.

The report of the Oregon Department of Human Services on the ODDA has not been without its critics. Foley and Hendin (1999) contended that since the ODDA does not require a psychiatric evaluation for all those who requested assisted death, the report could not have accurate information about the degree to which depression might have impaired the judgment of those making requests. They also argued that the report is based solely on information obtained from physicians and provided no data on how thoroughly physicians assessed the reasons for patients’ requests.

The arguments for and against assisted death for the competent, terminally ill patient who requests it have been discussed at length by Kleespies (2004), by Rosenfeld (2004), and by Werth and Wineberg (2005) among others. It is beyond the scope of this chapter to repeat them here. One concern of the opponents to assisted death, however, has not been supported by the Oregon data. It has been argued that the legitimization of assisted death will put us on a slippery slope where it will be too easy for the less scrupulous to coerce vulnerable people who are (p. 395) lacking in resources to accept it. The Oregon data suggest that those who have sought assisted death have not been particularly vulnerable, but have actually been people who are relatively well educated and who have had health insurance and hospice services.

Concluding Remarks

In assessing for suicide risk, the mental health clinician must take into account, among many other factors, the presence of mental illness, particularly depression, bipolar disorder, schizophrenia, and alcohol use disorder. There is increasing evidence, however, that certain physical illnesses, the functional impairments that they engender, and/or the prospect of deteriorating physical health are also risk factors for suicide that the clinician is well advised to consider in arriving at an estimate of risk. Untreatable illnesses such as HIV/AIDS (before the introduction of HAART) and incurable conditions like Huntington’s Disease have been known to entail great suffering with little hope of survival. Such circumstances can easily lead to despair and suicidality. Especially in the elderly, coping with multiple physical illnesses and conditions can affect the quality of life and become a burden that is hard to bear.

It is of interest that the most frequent end-of-life concerns of the terminally ill who made use of the ODDA were loss of autonomy, a decreasing ability to participate in activities that made life enjoyable, loss of dignity, and loss of the control of bodily functions. I suspect that many of these concerns are shared by those who have diseases such as multiple sclerosis and end-stage renal disease who become suicidal. A focus on finding ways to diminish these concerns may go a long way toward increasing meaning, instilling hope, improving quality of life, and decreasing the risk of suicide in those for whom physical illness is a risk factor.


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                                                                                                                                                                                                                        (1.) In general, those who are opposed to physician assistance in hastening death in the terminally ill refer to this type of death as “assisted suicide,” while those who support it do not consider it suicide and use the term “assisted death.”

                                                                                                                                                                                                                        (2.) Data on those who have used the Washington Death with Dignity Act can be obtained at and information about the recently enacted Vermont Death with Dignity Act can be found at