Suicide and End-of-Life Care
Mary Ann Cohen
This chapter addresses two of the most challenging aspects of the care of persons with human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS)— suicide and end-of-life care. Although there are commonalities, each of the topics is presented separately. Some of the precipitants of suicide are also issues at the end of life in patients with HIV disease and AIDS. For example, intractable pain, severe pruritus, end-stage renal disease, and depression, as well as other psychiatric disorders, lead to high levels of distress in persons with AIDS long before the end of life. Each of these symptoms and illnesses alone may be risk factors in vulnerable individuals. These are also important factors to address at the end of life. AIDS psychiatric care and palliative care need to be integrated and offered to persons throughout the course of illness. This concept serves as the introduction to the first section of this chapter and emphasizes the need for alleviating distress and suffering, finding meaning, maximizing life potential, and networking with families and loved ones to prevent suicide in persons with HIV and AIDS.
Suicide
Suicide is one of the most tragic of the psychiatric aspects of AIDS. Although suicide may or may not be associated with mental illness, it is frequently associated with psychiatric disorders in persons with medical illness. Persons with medical illnesses such as cancer, end-stage renal disease, Huntington’s disease, and AIDS have been found to have a high prevalence of suicide,1,2,3,4,5,6,7,8,9,10,11 and those who are suicidal have been found to have a high prevalence of psychiatric disorders such as mood disorders, substance use disorders, and psychotic disorders. In persons with AIDS, HIV-associated cognitive disorders, delirium, and dementia12 further complicate the picture and increase suicide risk. Stigma and discrimination associated with HIV infection may play a dual role in the increased suicide risk in persons with HIV infection. Stigma leads to higher levels of distress and magnifies other psychiatric symptoms. Stigma and fear of discrimination result in alienation from friends and family. Although problems with disclosure were more prevalent in the first two decades of the HIV pandemic, some persons with HIV infection continue to hide their diagnoses from family and friends. This diminishes the network of psychosocial support so critical in suicide prevention.
The first half of this chapter addresses the magnitude of the problem of suicide in persons with AIDS, the sources of suicidality, the risk factors for suicide, the psychiatric and medical comorbidities, how to assess for suicide risk, and how to prevent the tragedy of suicide.
Scope
Suicide is the eleventh leading cause of death in the United States. Approximately 29,000 people commit suicide in the United States each year, with a rate of suicide of 10.8 per 100,000 in the general population. There are 10 to 25 suicide attempts for every completed suicide. The risk factors for suicide in general are all magnified in persons with severe medical illnesses such as AIDS. Most of the studies of the rate of suicide in persons with HIV infection and AIDS were done early in the epidemic. The rate of suicide in these studies ranges widely from 7.4 to 66 times greater than that in the general population,8,9 or approximately 80 to 713 per 100,000 people.
Prevalence and Risk
Suicide, medical illness, and psychiatric illness are inextricably linked in persons with HIV disease and AIDS. Suicide risk has been found to be higher in persons with chronic medical illness than in the general population.1,2,3,4 Suicide is more prevalent in persons with end-stage renal disease, cancer, Huntington’s disease, and AIDS.5,6,7,8,9,10,11 In persons with AIDS, the wide range in suicide prevalence, from 7.4 to 66 times greater than the general population, reflects the multiplicity of disparate cohorts and times of studies.8,9,10,11 Most studies indicate that persons with AIDS or HIV infection are at an increased risk for suicide. Marzuk et al.9 studied the rate of suicide in New York City during 1985. He found that the suicide rate for men with AIDS from 20 to 59 years old was 36 times that of men from 20 to 59 years without a diagnosis of AIDS and 66 times that of men of all ages combined. Coté et al.8 studied all death certificates indicating both AIDS and suicide in the United States from 1987 through 1989. He found a 7.4-fold higher rate of suicide in persons with AIDS. Drug overdose accounted for 39% of suicides, followed by firearms (25%) and suffocation (13%). Rajs and Fugelstad13 reviewed 21 completed suicides in Stockholm over a period of 5 years. Medicinal drug overdose was also found to be the most prevalent suicide method. Older individuals14 and women are particularly at a higher risk for suicide. In a sample of HIV-infected persons from Milwaukee, Wisconsin, and New York City, Kalichman et al.14 found that 27% of respondents reported suicidal ideation within 1 week before the survey. In a more recent New York City autopsy study, Marzuk et al.15 found HIV-positive men of African- American and Latino American ethnicity, aged 35 to 54 years, to be at the highest risk for suicide.
Erfurth et al.16 in Munich documented that the two most common reasons for psychiatric consultation in patients with AIDS were for evaluation of suicidal behavior and treatment of depression. Suicidal behavior was present in 1 of 5 patients with HIV seropositivity or AIDS in a general hospital population.10 Woller et al.17 studied a cohort of HIV-infected gay men and found that suicidal behavior is related more to rejection by key persons or significant others than to disease stage or immune function.
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
