Suicide Risk and Suicide in End Stage Renal Disease ...

Suicide Risk and Suicide in End Stage Renal Disease Patients Tony Salvatore1, Kimberly D. Dodson2, Trisha M. Kivisalu3, Diane Harr4, & Jerrod Brown,4,5,6 1Montgomery

County Emergency Service, Norristown, PA, USA; of Houston - Clear Lake, TX, USA; 3UT Health, San Antonio, TX, USA; 4Concordia University, St. Paul, MN, USA; 5Pathways Counseling Center, Inc., St. Paul, MN, USA; 6American Institute for the Advancement of Forensic Studies, St. Paul, MN, USA 2University

ABSTRACT

End stage renal disease (ESRD) is the terminal phase of chronic kidney disease. It affects more than 100,000 persons in the United States annually and claims over 80,000 lives each year. ESRD patients acquire and accumulate a broad range of significant risk factors for suicide. The nature of the illness, the demands of its treatment, and the debilitating effects it has on overall health, functioning, autonomy, and outlook may trigger suicidal ideation in patients. Depression, anxiety disorders, and other forms of mental illness are common in this population. The ESRD disease process and its psychosocial consequences weaken protective factors and buffers against suicidality, such as hopefulness and reasons for living. Research shows a high incidence of suicidal thoughts, suicide attempts, and suicide mortality. Such exposure to suicide risk warrants strong

The Forensic Mental Health Practitioner, Vol. 1, Issue 1, 2018 A Publication of the American Institute for the Advancement of Forensic Studies (AIAFS)

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and pervasive suicide prevention measures on the part of dialysis providers, including more information and education for patients and families.

Keywords: End Stage Renal Disease (ESRD), Kidney Failure, Kidney Disease, Suicide Suicidal Behavior in End Stage Renal Disease Patients

End Stage Renal Disease (ESRD) is a severely debilitating condition with an insidious onset that leaves most of those it affects dependent on a treatment technology which dominates their lives. ESRD involves irreversible, kidney failure affecting approximately 117,000 Americans every year and claiming the lives of about 89,000 yearly (National Kidney Foundation, 2018). ESRD affects children, youth, and adults. The impact of ESRD may influence a person’s sense of hope and provoke thoughts of death. Those living with ESRD may experience suicidal ideation, attempt suicide, and die by suicide. While the incidence of ESRD has slowed in recent years (United States Renal Data System, 2016) this population remains at an elevated risk of suicide. More research needs to be conducted to identify risks of suicidality among individuals living with ESRD. This paper outlines ESRD, suicidality, as well as offers intervening questions providers and family can ask in efforts to identify and intervene with suicidal behavior. Predominantly, ESRD is treated with dialysis or, in rare cases, a kidney transplant. In the United States, there are more than 660,000 ESRD patients, of whom 468,000 are on dialysis (United States Renal Data System, 2015). Ninety percent of ESRD patients are on hemodialysis that involves traveling to a dialysis center three times weekly for treatments lasting about four hours, in which the blood is cleaned of toxins through a dialysis machine’s filtration system (National Kidney Foundation, 2015). ESRDis irreversible and causes significant lifestyle changes. Moreover, the impact of ESRD affects mental health and wellness. An estimated 20%25% of those living with ESRD experience depression (Kimmel, Cukor, Cohen, & Peterson, 2007) and over 45% experience anxiety (Yoong et al., 2017).

Precipitating Factors to ESRD


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There are multiple possible factors that contribute to the development and ultimate diagnosis of ESRD. According to American Kidney Fund (2018), the most common cause of ESRD is diabetes and the second is hypertension. ESRD may also be the result of a variety of factors from genetic conditions such as polycystic kidney disease, autoimmune diseases such as lupus, nephrotic syndrome (several conditions affecting kidney function), urinary tract problems, (substance abuse and other social and lifestyle choices and nutritional elements (American Kidney Fund, 2018). Noncompliance with care of diabetes and hypertension play a significant role in the etiology of ESRD (DeSousa, 2008). This disease also exposes patients to a host of other morbidities, most notably infection, stroke, or a heart attack. ESRD permanently, and negatively, changes a person’s lifestyle. For example, it impacts their sense of personal control, restricts social functioning, requires patients to constantly modify their nutritional balance, overwhelms the ability to cope and adjust, and in many cases, brings on feelings of anxiety and depression (Finnegan-John & Thomas, 2013). The combination of the invasive treatment interventions, coupled with the changes in mood and well-being can exhaust the ability to cope leading to helplessness, hopelessness, and even suicide. Overall, ESRD patients, especially those on hemodialysis outside the home, have a poor prognosis and quality of life, and a strong risk profile for potential suicidality. Deaths by suicide have long been documented in ESRD patients (see Abram, Moore, & Westervelt, 1971). There has been some contention as to exactly what constitutes a death by suicide in ESRD patients. In some instances, patients elect to terminate treatment, which is followed by death within a brief period (Cohen, Bostwick, Mirot, Garb, Braden, & Germain, 2007). Patients deciding to do so are mostly older, more dependent, and have greater morbidity and pain (Kilger & Finklestein, 2003). Improved accessibility and availability to mental health services has been proposed for such patients (Davidson, 2012). Depression and suicidal ideation have not been found in the majority of ESRD patients making this decision, but some patients believe ending treatment is equivalent to suicide (Cohen, Dobscha, Hails, Pekow, & Chochinov, 2002). A guide to voluntarily terminating dialysis published for ESRD patients and their families advises readers to seek the opinion of clergy and other pastoral resources to determine if the decision to stop dialysis is a suicidal act (National Kidney Foundation, 2006.) Deaths by suicide among those living with ESRD are rare, but the risk of suicide is greater than that in the general population (Kurella, Kimmel, Young, & Chertow, 2005). One The Forensic Mental Health Practitioner, Vol. 1, Issue 1, 2018 A Publication of the American Institute for the Advancement of Forensic Studies (AIAFS)

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source reports the death by suicide rate in ESRD patients to be 15 times that of the population in general (Patel, Sachan, Nischal, & Surendra 2012). The Centers for Disease Control and Prevention (2018) report the rate of suicide for the U.S. was 13.5 suicides per 100,000 population. The suicide rate for ESRD may be over 200 suicides per 100,000. Another source indicates that as many as five percent of hemodialysis patients die by suicide (Buzan & Weissberg, 1992), although this data is outdated. Unfortunately, research in this area is limited since the deaths by suicide are not among the causes of death officially reported for ESRD patients. The United States Renal Data System (2015) reports that the cause of death is missing or unknown for twenty-four percent of dialysis patients and it is unknown exactly what proportion of these may have been deaths by suicide. A concern underlying the inordinately high claims of suicide incidence in the ESRD population is that many or even most of the deaths regarded as suicides may have resulted from treatment noncompliance that did not involve the intent to die characteristic of a suicide (Bostwick, 2015). Patients with chronic kidney disease are included in the roster of “groups with increased risk of suicide” presented in the 2012 National Strategy for Suicide Prevention: Goals and Objectives for Action: A Report of the U.S. Surgeon General and of the National Action Alliance for Suicide Prevention (Office of the Surgeon General, 2012, p. 114).

The Nature of Suicidality in ESRD Patients There is a full range of possible suicidal behaviors that may be exhibited among those living with ESRD (Pompili et al.2013). Some of the suicidal behaviors include thoughts of suicide, expressions of intent to attempt suicide (i.e., verbal threats or nonverbal actions such as giving away precious/valued items), developing a specific suicide plan (when, where, how), and making a suicide attempt (Nock, Borges, Bromet, Cha, Kessler, & Lee, 2008). The possibility of lethality rises as behaviors beyond ideation increase, although it is important to note that individuals differ greatly in their presentation of suicidality; it is not linear progression. In fact, individuals may have thoughts, plans, and intention that goes completely unannounced to those around them. Additionally, there are some individuals who died by suicide and exhibited impulsivity, that is, the thought, plan, and intention were based on an impulse which was then carried out quickly. The latter is often a factor in assessing individuals for their potential for


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suicide among health professionals and a history of impulsivity among those who express suicidal ideation is often a warning sign for more immediate intervention. Suicidal ideation is the most common suicidal behavior (Piscopo, Lipari, Cooney, Glasheen, 2016). In 2015, 9.8 million adults aged 18 or older in the U.S. thought seriously about trying to kill themselves in the past twelve months (Piscopo et al., 2016). Such thoughts may arise as a means of escape, or in efforts to impose control in amongst adverse life circumstances. Ideation may be triggered by setbacks in their condition. For example, in lieu of receiving a successful kidney transplant, individuals living with ESRD have a life-long dependence on a stressful treatment for an illness affecting every aspect of their life. Moreover, they are also exposed to the debilitation and deaths of other patients. Patients may also acquire the knowledge that they can end their lives by mismanaging their diet or missing a few treatment sessions. The prevalence of depression is higher in patients with ESRD than in the general population (Patel et al., 2012). It is also common in those patients on hemodialysis treatment (Kimmel et al, 2007). While depression does not cause suicide, it is a significant risk factor (Nock, Borges, Bromet, Cha, Kessler, & Lee, 2008). Another major risk factor is hopelessness, which is a state of mind rather than a disorder consisting of negative beliefs about the future and one’s inability to improve their prospects (Abramson, Metalsky, & Alloy, 1989). Given the strife and challenges in physical health as well as the mental energy to undergo extensive treatment interventions, it is possible that hopelessness may emerge in an individual living a life dominated by ESRD and dialysis. Like depression, hopelessness may be a significant contributor to suicidality. The risk of suicide has been determined to be highest in the three months after dialysis started and less so thereafter (Kurella et al., 2005). It is plausible to infer this may be because depression and hopelessness are highest in that period. Noncompliance with dialysis treatment and the decision to terminate care are not regarded as suicidal behavior because factors other than intent to die may be present. However, these behaviors may involve “passive suicidal ideation” which involves the desire, if not explicit intent, to have one’s life end (Simon, 2014, p.14). This type of suicidal thought is felt to be a clear sign of suicidality (Baca-Garcia, Perez-Rodriguez, Oquendo, Keyes, Hasin, & Blanco, 2011). Those individuals who exhibit non-compliance with treatment interventions are in an atrisk situation because it may give way to “passive suicide.” This may be characterized by nutritional self-neglect or non-adherence to necessary medical regimens, not keeping The Forensic Mental Health Practitioner, Vol. 1, Issue 1, 2018 A Publication of the American Institute for the Advancement of Forensic Studies (AIAFS)

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appointments, or refusing requisite medical attention. From a treatment perspective, such disregard for one’s welfare reflects a devalued self-worth and depletion of hopefulness, both of which are strongly associated with suicide risk.

How Does a Suicide Happen? Suicide has been defined as “the act of intentionally ending one’s own life” (Nock et al., 2008). It is the outcome process driven by intent and following a specific plan. The danger level rises sharply when a plan for completing suicide takes shape. A plan specifies how a suicide will be conducted (i.e., means), when it will occur, and where it will take place. Potential dangers exist for those living with ESRD as they have ready access to lethal means. Simply not adhering to treatment and, in many cases, a failure to take prescribed medications can be the basis of a suicide plan that is able to be enacted by even the frailest patient. It is also possible they may access means used by the non-ESRD population such as overdose, firearms, toxins, asphyxiation, hanging, jumps, and falls. A suicide attempt requires an intense desire to die and the capability for lethal self-harm (Joiner, 2005). The first may be generated by the belief that one is a burden to others and they would be better off if they were dead. In addition, an individual’s belief that they are completely disconnected from those they care about may lead to a desire to die. The ability to harm one’s self requires overcoming the natural survival instinct and resistance to lethal self-harm (Joiner, 2005). It may come about from multiple means including prior self-injury, abuse, or exposure to violence; however, it may also result from intense suffering and exposure to pain and painful treatment procedures. Suicide also can be precipitated by ruminative thoughts, plans, and envisioning enacting the plan prior to its execution. Lowered resistance to lethal self-harm and increased capability for suicide also are postulated to result from exposure to pain (Joiner, 2005). Studies of quality of life in dialysis patients have identified pain as a frequent complaint (Kimmel, Emont, Newman, Danko, & Moss, 2000). Patients with chronic kidney disease may experience an ongoing range of surgical interventions related to vascular access and to medical problems related to comorbid conditions. Exposure to frequent surgeries and invasive procedures have been theorized as a pathway to the


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development of higher pain tolerance which is a contributing factor to the capability for enacting suicide plans (Joiner, 2005).

The Sources and Signs of Suicide Risk in ESRD Patients

There are several possible factors that may contribute to suicidal ideation, plans, and intent. As health professionals, it is imperative to understand the sources of distress as well as the signs that signal intervention to address suicidality. Suicidal ideation and plans, if detected and directly assessed can be effectively treated to reduce the rates of suicide, especially among those living with ESRD. People living with ESRD may have pre-existing suicide risk factors, which may be activated and aggravated by the onset of chronic kidney disease. Such pre-existing risk factors may include mental illness, lack of social support, marital and family conflict, unemployment, financial and housing issues, other health concerns, and perception of the burden of illness (Kimmel, 2001). Other risk factors play a more predominant role with the initiation of dialysis, which severely limits autonomy and self-sufficiency and both characteristics which have been linked to thoughts and ideas of suicide (Hill & Petit, 2013). Employment or is frequently an early casualty of chronic kidney disease as is the sense of identity, accomplishment, and social connectedness that it provides. There are also interpersonal factors to consider, research suggests a greater likelihood of suicidality in those individuals living with ESRD is associated with being single or divorced, believing family members and friends are less supportive, and having low satisfaction with life (Soykan, Arapasian, & Kumbasar, 2003). Depression is a predominant psychiatric disorder in dialysis patients (Chen et al., 2110). A meta-analysis of over 200 studies placed the prevalence of depression in patients with ESRD and chronic kidney disease from 23% to 39% (Palmer et al., 2016). Suicide risk increases with the presence of depression and the existence of background factors such as substance abuse, past suicide attempts, a family history of suicide, poor social support, isolation, feeling disconnected, or lacking a sense of belonging. Research shows depression is also strongly related to decreased treatment compliance in ESRD patients (Kimmel, Peterson, Weihs, & Simmens, 1998). Another factor that can increase depression symptoms and suicidal ideation, is the experience of sleep disturbances and a preoccupation with body image, both of which are found in ESRD patients (Finnegan-John & Thomas, 2013). The Forensic Mental Health Practitioner, Vol. 1, Issue 1, 2018 A Publication of the American Institute for the Advancement of Forensic Studies (AIAFS)

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There are also demographic and personal characteristics that contribute to suicide risk in an ESRD patient, almost 60% of whom are male and less than one-half of whom are ages adults 20-64 and just over one-half are elders age 65 and over (United States Renal Data System, 2018). This overlaps with populations at risk of suicide who are predominantly adult Caucasian males (ages 24-44) or older adult males (age 65-80), having a history of suicide attempts and/or cutting, other self-injury; co-occurring mental illness, especially depression, and/or alcohol abuse, and/or being separated, divorced, or widowed. Another factor for consideration is substance abuse, which is known to be highly prevalent in ESRD patients. Research indicates that alcohol and drug use are associated with suicide in this population (Kurella et al., 2005). The major dangers and early warning signs of suicide risk are the same for ESRD patients as for other individuals. The following signs may indicate suicidality in an ESRD patient (Martiny, Cardosos, Simoes, & Nardi, 2010): demonstrating or stating a sense of hopelessness; feeling trapped and as though there is no reason for living; no perceived way of handling or dealing with their own health or life concerns; reduced problem-solving ability; withdrawal from family, friends, or caregivers; an increase in anxiety, agitation, more sleep problems (less sleep, or more sleep than usual for the person), dramatic mood changes or swings (more distinct and extreme than usual for the person), increased recklessness, increased risktaking behavior, more impulsivity, and a heightened indifference to treatment. A patient with one or more of the warning signs or behaviors should be promptly seen by the dialysis facility social worker or a mental health professional. Dialysis facility staff can use these questions to screen for suicide intent and capability: 

In the past few weeks have you wished you were dead?

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Do you feel less hopeful about your future?

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Do you feel that you do not belong anywhere?

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Do you feel that your life isn’t worth anything?

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Do you feel that people you care for would be better off without you?

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Have you been having thoughts of killing yourself?

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Have you thought about taking your life recently?

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Are you thinking about it right now?

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Have you mentally practiced or rehearsed a suicide plan? The Forensic Mental Health Practitioner, Vol. 1, Issue 1, 2018 A Publication of the American Institute for the Advancement of Forensic Studies (AIAFS)

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

What is your plan?

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When do you plan to execute your plan?

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How do you plan to end your life?

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Have you ever attempted suicide in the past? How? What happened? How many times?

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What steps have you taken about your current plan? (Joiner, Van Orden, Witte, & Rudd, 2009).

Seventy-seven percent of suicides in the U.S. take place at home (Karch, Dahlberg, & Patel, 2010). This is presumably true for ESRD patients as well, but there is no concrete data that currently exists, about suicides in this population, to substantiate this assumption. Nonetheless, some patients may manifest warning signs of suicide at a treatment facility, such as talking, writing, or texting about death, dying, or suicide, threatening suicide, voicing a specific suicide plan, or seeking means to carry out the plan. When any of these earning signs are present, a call to a local crisis center is appropriate. If possible, the patient should be persuaded to stay at the center or if this is not possible, the local police should be asked to make a welfare check at the patient’s home. Consideration may be given to an involuntary psychiatric evaluation if the patient will not agree to help and is an imminent danger to themselves or others.

Protective Factors against Suicide for ESRD Patients

Protective factors are individual characteristics a person either possesses or feels that function to deter or reduce the likelihood of suicidal behavior (Malone, Oquendo, Haas, Ellis, Shuhua, & Mann, 2000). Unfortunately, these buffers do not seem to have been extensively studied in ESRD patients. However, they may be challenging to assess in this population because of the debilitating physical and psychological consequences of the illness. More specifically, challenges include dietary and time constraints, functional limitations, loss of employment, changes in self-perception, alterations in sexual function, general and perceived effects of illness, medications used to treat the illness, and fear of death (Kimmel, 2001). Despite these challenges, some buffers may remain present, to some degree, and be a basis for reducing or at least defending against suicide risk.


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Some ESRD patients may have challenges in maintaining healthy levels of many buffering factors, which may function to deter suicidality such as optimism for the future, hopefulness, and good coping and problem-solving skills. However, they may still have strong, family and community support (connectedness) and beliefs and values that may counter selfharm. Promoting reasons for living may help. Treatment for depression and other psychiatric disorders, if present, may lessen the risk produced by such conditions. The literature on longterm dialysis patients suggests that attitude toward the disease and a sense of control over the disease contribute to longevity (Curtin, Mapes, Petillo, & Oberley, 2002). Changing ESRD patients’ perspective on their illness may have significant impact on suicide prevention. More specifically, use of Acceptance and Commitment Therapy (ACT) (see Hayes, 2005) has been demonstrated to be effective for individuals living with chronic pain and severe illness conditions (McCracken & Vowles, 2014). ESRD patients lose many of the social connections they enjoyed prior to becoming dependent on dialysis. The treatment regimen itself tends to isolate ESRD patients, or at least significantly limit their social interaction. This may promote a sense of not belonging, which has been identified as a pivotal factor promoting a desire to die (Joiner, 2005). Preserving or restoring connectedness should, therefore, be a key component of suicide prevention in the ESRD population. Connectedness is the degree to which an individual is socially close or interrelated with other individuals and, as previously noted, these relationships can be protective and prevent against suicidal thoughts and behaviors (Centers for Disease Control and Prevention, 2011).

CONCLUSION

The foregoing review illuminates the concern that individuals living with ESRD may, by exposure to multiple intrusive treatments, likely have existing risk factors for suicide. They may also express well-recognized suicide risk factors because of their illness and its effects on their lives. It is documented that suicidal behaviors from ideation to completing suicide occur in this population more frequently than in the non-ESRD population. This suggests that ESRD patients need to be targets for suicide prevention. Such measures can be most readily and effectively implemented in dialysis centers where individuals living with ESRD spend a significant amount of time in treatment, and where most of their care is provided and monitored. The Forensic Mental Health Practitioner, Vol. 1, Issue 1, 2018 A Publication of the American Institute for the Advancement of Forensic Studies (AIAFS)

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Suicide risk screenings should occur, for new patients, at the outset of dialysis to identify any risk factors that may be present. Risk also should be assessed periodically over the course of treatment, but especially early on. All facility staff with patient contact, as well as paratransit personnel, should be familiarized with warning signs, and be trained in suicide assessment. Family members need to be advised of the possibility of suicidal behavior as they may be able to recognize early warning signs in the home. Facility nursing and social work staff can work to promote optimism, reasons for living, good coping, and resilience. Patients should be counseled on the prospect of suicidal ideation and urged to bring it to the attention of facility staff. Referrals to community therapists, psychologists, or licensed mental health professionals should be made available and given to all ESRD individuals and families. Each of these interventions and steps need to be implemented as part of a facility suicide prevention policy outlining what must be done to reduce risk, respond to suicidal behavior, and provide postvention support to patients’ families and medical staff if a patient dies by suicide. Suicide is preventable and requires awareness, knowledge, training, and support, to effectively reduce rates of suicide among those with ESRD.


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