Depression and suicide in men: Identifying the risk

Dr. Welk is assistant professor in the division of urology at Western University, London, ON.

In the United States, millions of men are diagnosed with depression each year. In the most extreme cases, this can lead to self-harm behavior or suicide. One person dies by suicide every 40 seconds, and it is the tenth most common cause of death in the world; depression exists in over half of people who commit suicide (Lancet 2009; 373:1372-81).

Older men are at the highest risk of suicide, making this a relevant topic for urologists. In addition, it is common for suicide to be preceded by significant life events, such as a new health-related diagnosis. In urology, one of the most common and potentially impactful diagnoses is the confirmation of a genitourinary malignancy. Research has shown that the risk of suicide is increased after the diagnosis of bladder, kidney, prostate, and testis cancer (Cancer Care 2017; 26:e12635).

This article discusses the risk of depression and suicide in men, focusing on increased risk in men with genitourinary cancer and other urologic conditions.

Urologic disease and depression/suicide

Prostate cancer. Given the prevalence of prostate cancer and the high proportion of men who are cured or have a long survival after diagnosis, the risk of depression and suicide has been well studied. The diagnostic process itself is stressful for patients, and the high intensity of medical tests and physician appointments in the weeks prior to the diagnosis of cancer places patients at a higher risk of depression and self-harm (BMJ 2016; 354:i4218).

Several analyses have demonstrated that about 60% of men experience significant distress after their diagnosis (such as anxiety, post-traumatic stress disorder, and affective disorders), and up to 40% will meet the clinical criteria for a depressive disorder. The reasons for this are variable and include the obvious psychological stress of a cancer diagnosis, the emotional impact of urinary incontinence and erectile dysfunction after treatment, changes to body image, and the direct effects of prostate cancer therapies such as androgen deprivation therapy (which may increase depression risk directly by dysregulating serotonin [J Clin Oncol 2016; 34:1905-12]).

The identification of a cancer patient with depression is challenging and often obscured by the assumption that signs or symptoms represent a normal reaction to a serious diagnosis or are side effects of therapy. While there are several validated questionnaires available, their use in day-to-day urology practice is likely not practical (Cancer Care 2017; 26:e12635).

Among men with prostate cancer, the risk of suicide is 40% to 50% higher than the general population, and men with metastatic disease or high-risk localized disease seem to have an even higher rate of suicide (Urol Oncol 2018; 36:60-6). It is important to recognize that the risk of suicide remains elevated even years after definitive treatment, which implies that the changes that persist after the oncologic treatment of prostate cancer (eg, incontinence, erectile dysfunction, and late complications such as radiation cystitis and hypogonadism) likely impact suicide risk in this population.

General risk factors for suicide in cancer patients are listed in the table. In practice, urologists should be vigilant for patients with risk factors after the diagnosis of a genitourinary malignancy, especially since 75% of patients who complete suicide visit a physician in the 30 days before their death.

Next:Other urologic conditionsOther urologic conditions. Outside of urologic oncology, depression has been linked to several other urologic conditions in both men and women, such as renal stone disease, urinary incontinence, and lower urinary tract symptoms secondary to BPH. In children, those with voiding dysfunction or enuresis may have a higher rate of psychosocial difficulties. Some medications may also be linked to depression, with research showing a higher risk of depression among women with overactive bladder who are treated with anticholinergic drugs (vs. those who are untreated) and among men who are treated with 5-alpha-reductase inhibitors.

Available resources

Mental wellness weaves itself into many different medical conditions, and urology is no exception. Among urologists who treat cancer patients, it is particularly important to recognize the importance of psychological health after diagnosis and treatment. An assessment of the patient that goes beyond the most recent post-treatment PSA level is also important to a patient’s survival, and for the busy surgeon, establishing a multidisciplinary network of related health care professionals should be a priority. Being able to offer patients hope and therapeutic options for consequences of cancer treatment can provide them with optimism and options. Examples include referral to a colleague who can offer surgical options such as an artificial urinary sphincter or penile prosthesis and referral to a sex therapist who can teach couples about intimacy after cancer.

Survivorship has gained increased importance, and the American Cancer Society prostate cancer survivorship care guidelines highlight this issue (CA Cancer J Clin 2014; 64:225-49). If a urologist is faced with a patient who he or she believes may be at increased risk for suicide, it is critical to ask about suicidal ideation and plans. In this situation, further questions about the proximity and details of these plans are necessary. Based on the person’s answers, and especially in a patient who communicates an explicit intention to die, an emergent referral to a psychiatrist is necessary.

Section Editor Steven A. Kaplan, MD, is professor of urology, Icahn School of Medicine at Mount Sinai, New York.