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FROM THE ACADEMY OF CONSULTATION-LIAISON PSYCHIATRY

Although vitamin deficiencies and their associated adverse effects are usually considered a public health problem in the developing world, they remain an important clinical consideration for select populations across the globe. In fact, there is concern that we may be confronted with increased negative consequences of poor nutrition due to decreased testing and screening and less education in our medical institutions about the importance of good nutrition to optimal health.

Casimir Funk, PhD, discovered that key nutrients, which he termed 

, are essential to maintaining good health and that deficiencies in these key nutrients led to pathognomonic disease states. This realization was a result of observing birds that were fed a diet of polished rice and developed a diffuse polyneuritis (beriberi). The same birds were then fed a diet of brown rice, and their “nervous symptoms rapidly disappeared.”

 This experiment helped establish the importance of vital amines, later shortened to “vitamin.”

Vitamins can be broadly delineated into water-soluble and fat-soluble categories. Water-soluble 

 are typically absorbed very quickly via the gastrointestinal tract and widely distributed in various tissues throughout the body. However, because these vitamins are water soluble, they are not efficiently stored in tissues. Therefore, this class of vitamins requires regular consumption (either through diet or supplementation) to avoid deficiency. Conversely, fat-soluble vitamins are more easily stored, typically in adipose tissue; therefore, they require less frequent intake.

 Examples of water-soluble and fat-soluble vitamins can be found in 

, also known as folate or folic acid, is crucial for DNA synthesis and repair, as well as the metabolism of amino acids involved in methylation reactions.

, folate deficiency can lead to neural tube defects in the fetus.

 In adults, folate deficiency can result in multiple neuropsychiatric symptoms. These symptoms may include cognitive impairment, insomnia, psychosis, depression, peripheral sensory deficits, and weakness. These manifestations are very similar to those of vitamin B

 deficiency. In patients with depression, folate deficiency can contribute to severity and can impede depression treatment.

Folate, which is absorbed in the small intestine, is obtained via diet or supplementation. Select food sources of folate or folic acid can be found in 

 Most serum folate is found in its active form, methyltetrahydrofolate (methyl THF). Methyl THF undergoes a B

-dependent enzymatic reaction, donating its methyl group to form tetrahydrofolate, which, in turn, is later involved in DNA formation. Any disruption in this process can lead to a deficiency in folate and its associated manifestations.

Folate deficiency can manifest from several different causes. High anabolic states, such as pregnancy, can result in increased utilization and depletion of folate stores. Similarly, chronic alcohol abuse causes poor absorption, impaired metabolism, and increased destruction of folate. Even moderate amounts of alcohol (for instance, 8 oz of red wine or 2.7 oz of vodka per day for a 2-week period) have been shown to reduce folate levels in otherwise healthy men.

 Certain medications have been shown to contribute to folate deficiency. A summary of common medications as well as their mechanism of folate deficiency can be found in 

Patients who appear to be at highest risk for deficiency include individuals with 

; individuals who take the noted medications (

); patients who require increased intake of folate (eg, pregnancy, hemodialysis, chronic anemias); and those patients with poor absorption because of intestinal dysfunction from surgery or inflammatory bowel syndromes. Women of childbearing age are also considered to be at risk. According to the 

National Health and Nutrition Examination Survey

, nearly 20% of women aged 14 to 30 years have inadequate serum levels of folate. The survey also found that almost 25% of non-Hispanic Black women have insufficient intake of folate compared with 13% of non-Hispanic White women.

Screening and testing should occur in individuals who are at high risk, have evidence of a macrocytosis or hyper-segmented neutrophils, and have unexplained neuropsychiatric conditions (eg, weakness, ataxia, paresthesia, 

Folic acid supplementation is recommended for all individuals who are at high risk. Evidence suggests that pregnant women should take at least 600 μg of folic acid daily to prevent neural tube defects.

 Folic acid is also typically given to patients on methotrexate to reduce adverse effects, although the dose given varies among rheumatologists.

 Patients with chronic hemolytic states and renal dialysis are recommended to take 5 mg daily to weekly, depending on requirement.

In 2018, a systematic review of survey data examined global folate status in women of childbearing age. Despite methodological limitations such as nonuniform measurement techniques and/or cutoff values, Rogers et al

 determined that the prevalence of folate deficiency was more than 20% in lower income countries and less than 5% in higher income countries. In January 1998, the United States implemented a mandate to fortify grain products with folate in an effort to 

 the incidence of fetal neural tube defects.

 Since then, folate deficiency has become very rare in the United States, with a prevalence of less than 1%.

Patients exhibiting macrocytic anemia on initial complete blood count and peripheral blood smear should be evaluated for both folate and vitamin B

 deficiency because these 2 conditions often present simultaneously. The diagnosis of folate deficiency is usually made when serum levels are less than 2.0 mcg/L.

 Measurement of serum homocysteine and methylmalonic acid (MMA) can also aid in differentiating between folate and B

 deficiencies. In folate deficiency, only serum homocysteine levels are elevated. In B

 deficiency, both homocysteine and MMA levels are elevated because B

 is involved in both homocysteine and MMA metabolism. Folate, on the other hand, has a role in only the homocysteine pathway

). Clinically elevated homocysteine can result in increased risk of thrombosis and its complications, such as myocardial infarction.

Oral replacement of folate is the recommended treatment. If the patient is unable to take oral medications, intravenous repletion is acceptable. The typical dose is dependent on the deficiency severity but ranges from 1 mg to 5 mg daily.

 Folate-deficient megaloblastic anemia due to dietary insufficiency or medications should be treated with 5 mg of folic acid daily for 4 months. Patients with malabsorptive states should be treated with up to 15 mg daily for 4 months.

s an associate clinical professor in the Department of Psychiatry at The University of North Texas Health Science Center at Fort Worth in Texas. 

 is a research coordinator in the Department of Behavioral Health Research at John Peter Smith Health Network in Fort Worth, Texas.

The authors report no conflicts of interest.

1. Adams KM, Kohlmeier M, Zeisel SH. Nutrition education in US medical schools: latest update of a national survey. Acad Med. 2010;85(9):1537-1542.

2. Piro A, Tagarelli G, Lagonia P, Tagarelli A, Quattrone A. Casimir Funk: his discovery of the vitamins and their deficiency disorders. Ann Nutr Metab. 2010;57(2):85-88.

3. Reinhard T. The Vitamin Sourcebook. NTC/Contemporary Publishing Group; 1998.

4. Chan YM, Bailey R, O’Connor DL. Folate. Adv Nutr. 2013;4(1):123-125.

5. Scott JM, Weir DG, Molloy A, McPartlin J, Daly L, Kirke P. Folic acid metabolism and mechanisms of neural tube defects. Ciba Found Symp. ١٩٩٤;١٨١:١٨٠-187; discussion 187-191.

6. Papakostas GI, Petersen T, Lebowitz BD, et al. The relationship between serum folate, vitamin B12, and homocysteine levels in major depressive disorder and the timing of improvement with fluoxetine. Int J Neuropsychopharmacol. 2005;8(4):523-528.

7. US Department of Agriculture (USDA), Agricultural Research Service, Nutrient Data Laboratory. USDA National Nutrient Database for Standard Reference, Legacy. Updated April 2018. Accessed January 19, 2021. 

8. Greenberg JA, Bell SJ, Guan Y, Yu YH. Folic acid supplementation and pregnancy: more than just neural tube defect prevention. Rev Obstet Gynecol. 2011;4(2):52-59.

9. Gibson A, Woodside JV, Young IS, et al. Alcohol increases homocysteine and reduces B vitamin concentration in healthy male volunteers--a randomized, crossover intervention study. QJM. 2008;101(11):881-887.

10. Hesdorffer CS, Longo DL. Drug‐induced megaloblastic anemia. N Engl J Med. 2015;373(17):1649-1658.

11. Tinker SC, Cogswell ME, Devine O, Berry RJ. Folic acid intake among US women aged 15-44 years, National Health and Nutrition Examination Survey, 2003-2006. Am J Prev Med. 2010;38(5):534-542.

12. Institute of Medicine (US) Standing Committee on the Scientific Evaluation of Dietary Reference Intakes and its Panel on Folate, Other B Vitamins, and Choline. Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline. National Academies Press; 1998.

13. Taylor PC, Balsa Criado A, Mongey AB, Avouac J, et al. How to get the most from methotrexate (MTX) treatment for your rheumatoid arthritis patient?-MTX in the treat-to-target strategy. J Clin Med. 2019;8(4):515.

14. Devalia V, Hamilton MS, Molloy AM; British Committee for Standards in Haematology. Guidelines for the diagnosis and treatment of cobalamin and folate disorders. Br J Haematol. 2014;166(4):496-513.

15. Rogers LM, Cordero AM, Pfeiffer CM, et al. Global folate status in women of reproductive age: a systematic review with emphasis on methodological issues. Ann N Y Acad Sci. 2018;1431(1):35-57.

16. FDA. Food standards: amendment of standards of identity for enriched grain products to require addition of folic acid. Federal Register. August 5, 1996. 

https://www.federalregister.gov/documents/1996/08/05/96-19803/food-standards-amendment-of-standards-of-identity-for-enriched-grain-products-to-require-addition-of

17. Khan KM, Jialal I. Folic Acid Deficiency. StatPearls Publishing; 2020.

18. Vuckovic BA, Cabarkapa VS, Ilic TA, Salatic IR, et al. Clinical significance of determining plasma homocysteine: case-control study on arterial and venous thrombotic patients. Croat Med J. 2013;54(5):480-488.

19. Lever EG, Elwes RD, Williams A, Reynolds EH. Subacute combined degeneration of the cord due to folate deficiency: response to methyl folate treatment. J Neurol Neurosurg Psychiatry. 1986;49(10):1203-1207.❒

A myriad of neuropsychiatric symptoms result from folate deficiency, including cognitive impairment, insomnia, psychosis, depression, peripheral sensory deficits, and weakness. Treatment and prevention strategies are discussed. 

Vital Amines: The Who, What, When, Where, Why, and How of Folate Deficiency

Sage Therapeutics announced 2 data sets from the ongoing phase 3 open-label SHORELINE study evaluating zuranolone: complete 12-month data from the 30 mg cohort and interim data from the 50 mg cohort. 

, a once-daily, 2-week therapy for the treatment of 

 (PPD), is an investigational oral neuroactive steroid (NAS) GABAA receptor positive allosteric modulator.

“Sage embarked on the LANDSCAPE clinical program to evaluate the safety and efficacy of zuranolone with the ambition of reimagining the treatment for depression with the goal of a rapid-acting, durable, treat-as-needed option in a disease where innovation is lacking and the incidence rate has unfortunately increased exponentially in the last 20 years,” Barry Greene, Chief Executive Officer at Sage Therapeutics, said to the press. “Today we are announcing additional positive data from the SHORELINE Study that demonstrate continued strong results from the 30 mg dose and strengthens our confidence in the potential of the 50 mg dose. Designed as a naturalistic study, these data approximate real-world evidence of use of zuranolone at 30 mg and 50 mg doses. We look forward to the results of the WATERFALL and CORAL Phase 3 pivotal data readouts in MDD this year.”

This clinical study was designed to evaluate the safety and tolerability of zuranolone 30 mg and 50 mg in adults for up to 1 year, and the currently analyzed data show that zuranolone was generally well-tolerated in both the 30 mg and 50 mg dose cohorts. Reported adverse events were generally consistent with results seen in previous zuranolone clinical trials; they included somnolence, headache, and dizziness.

In the 30 mg zuranolone cohort, 725 participants with MDD were treated with a first dose of zuranolone 30 mg once nightly for 14 days. Researchers evaluated participant response using the 17-item Hamilton Rating Scale for Depression (HAMD-17). The mean baseline HAM-D score (± SD) at entry was 25.3 ± 4.1 (n=725). Of the 725, 173 participants did not achieve response to the first course and left the study; however, 505 (73.5%) patients achieved response and 276 (40.2%) achieved remission (HAM-D ≤7).

From the initial group, 489 continued beyond the first treatment course. Of the 489, 210 used only the single initial course, 125 used 2 total courses, 58 used 3 total courses, 53 used 4 total courses, and 43 used 5 total courses. It was noted that adverse events decreased in frequency through the first 3 courses and remained stable over the next 2 courses.

From May 2020 onwards, all newly enrolled participants received 50 mg of zuranolone. The achieved response rate for these participants is 149/185 (80.5%), while the achieved remission rate is 80/185 (43.2%). This 50 mg cohort has completed the first course and the 12-month follow-up is expected to be completed in late 2021.

The SHORELINE study, as the first naturalistic, clinical development trial for MDD, is providing realistic insight into the potential use for zuranolone, if it is successfully developed and approved. Sage Therapeutics plans to report additional data from patients in the 50 mg dose cohort in late 2021, and present additional data from the study at conferences and in peer-reviewed journal articles.

1. Sage Therapeutics announces continued positive zuranolone data for both 30 mg and 50 mg doses in open-label SHORELINE study in patients with MDD. 

https://www.businesswire.com/news/home/20210317005285/en/Sage-Therapeutics-Announces-Continued-Positive-Zuranolone-Data-for-Both-30-mg-and-50-mg-Doses-in-Open-Label-SHORELINE-Study-in-Patients-with-MDD

New data from the ongoing SHORELINE study may bring good news for treating MDD. 

Incoming Data: News from Naturalistic MDD Clinical Trial 

Patients with cancer are at increased risk for both suicidal ideation and completed suicide due to a combination of biological and psychological factors that must be addressed to increase quality of life. More research is needed to determine the best methods of screening, evaluation, and treatment for suicidal thoughts and actions in this population.

- Cancers with the highest suicide risk include head and neck, lung, and pancreas.

- Health care providers do not feel adequately prepared to assess patients for suicidality.

- Increased risk is associated with older age, male gender, increased paid, lack of social supports, preexisting mood disorders, hopelessness; iatrogenic and biological factors must be assessed and addressed.

Cancer has plagued humanity since the beginning of recorded history. The first mention of cancer in the literature appeared in the Edwin Smith papyrus, dated ~3000BC. Surviving documents from ancient Greek and Roman physicians detail attempts at diagnosing and curing and give us the language we use today (oncos and cancer, respectively).

Although the overall prevalence of mortality due to cancer has been decreasing, it is still the second leading cause of death in the United States, responsible for 599,108 (21.3% of total) deaths in 2017.

 In comparison, suicide ranks 10th in this list, with 47,173 (1.7% of total) deaths. The most common cancers worldwide are lung, breast, 

, prostate, skin, and stomach; lung, colorectal, stomach, liver, and breast cancers account for the most deaths.

Changing attitudes toward suicide has altered the recorded prevalence over time, but it has always been a factor in human death. The desire to control, to some extent, the timing and manner of one’s death has always been a human temptation, and this draw increases when physical or emotional distress are present. Although estimates vary, patients with cancer are, at minimum, twice as likely to die by suicide. Moreover, having psychiatric care pre-diagnosis may not mitigate this increased risk.

Suicide risk is not the same for all types of cancer, nor is it consistent over the disease course (

).Several studies have found that suicide risk is at least twice that of the general population and is highest immediately after diagnosis.

Among cancers with the highest suicide risk are those affecting the head and neck, lung, pancreas, and larynx/pharynx. Prostate cancer has a higher suicide rate in the first year after diagnosis, but lower overall unless metastatic disease is found, with additional increased risk when treatment is defined but not received. Unique to cancer is that the risk of suicide persists more than 15 years past diagnosis.

In addition to increased suicide risk, patients with head and neck cancers have higher depression scores than the general population even before a cancer diagnosis, leading to the question whether this subset of patients are struggling with a biological cause in addition to diagnosis-related symptoms.

 Complicating these cases is the well-known association of many head and neck cancers with tobacco, alcohol, and other substance use, leading to the question of whether the pre-existing mood disorders lead to substance use that increases the risk of cancer. The relative increase in number of cases linked to human papillomavirus instead of substance use may alter this picture.

Regarding lung cancer, although the risk of suicide has been decreasing, Rahouma and colleagues6 found that these patients are at a higher risk than those with the more prevalent breast, prostate, or colorectal cancer. Furthermore, a large proportion of suicides may occur in patients with possibly non-fatal disease.

The risk in patients with breast cancer has been relatively stable over the last 4 decades and may be linked to whether the patient has undergone surgery. Findings from Simpson and colleagues

 indicate that penile cancer patients have one of the lowest suicide rates and, in their study, all patients who died by suicide had undergone surgical intervention. The link between surgical intervention and suicide risk may be linked to cosmetic effects, particularly as they affect sexual organs and can potentially alter patients’ view of their desirability and sexual roles.

In colorectal cancer, risk differs depending on the site of the lesion. Distally located disease is linked to a higher rate of suicide. This effect may be due to the more severe effects of distal disease on quality of life. Suicide risk in patients with stomach cancer was 

 with diarrhea, which can have a significant impact on lifestyle.

 It is not surprising that patients with terminal cancers report significantly more suicidal ideation.

One of the challenges in suicide prevention is determining the most effective ways to assess risk and screen for suicidal thoughts and intentions. Very little information has been collected regarding formal suicide risk assessment in cancer patients 

 found that health care providers did not feel adequately prepared to ask about suicidality or provide support and resources to patients.

The Columbia Suicide Severity Rating Scale (C-SSRS) is widely used for assessing suicidal intent, acts of furtherance, and suicide attempts. It has been studied and validated, and it is available in a variety of languages. It is free and designed to be used by anyone, including people without prior mental health care experience; there are versions specifically for people with cognitive impairments and children. However, it does not provide guidance as to full assessments or further steps once the screening is positive.

The Beck Hopelessness Scale asks true/false questions about future orientation, motivation, and expectations in order to assess negative feelings about the future. It can be used as an indirect evaluation of suicidal thoughts but does not address it directly. The detailed interpretation report can be very useful in assessing changes over time, but although the questions can be asked by anyone, the interpretation requires a trained professional.

The Hamilton Depression Scale (HAM-D) is a relatively brief questionnaire that asks about a variety of symptoms of depression; suicide is mentioned in 1 of the 17 questions, which are on a graded scale. It does not ask about atypical symptoms and, while it has relatively high sensitivity, specificity is low.

The Patient Health Questionnaire-9 (PHQ-9) is a brief set of questions designed to be asked and reviewed by any health care professional, with recommendations of when to advise further assessment by a mental health professional. It has shown to be reliable and valid in multiple studies. Like the HAM-D, it has relatively high sensitivity and low specificity.

Multiple studies have shown cancer as an independent risk factor for completed and attempted suicide. Spoletini and colleagues

 contrasted suicide in the general population, which they attributed to “genetic and psychological vulnerability to stress,” to suicide in cancer patients, which involved the “intrinsic bio-psychological vulnerability to distress” linked to changes in the immune system associated with cancer. Thus far, research has not identified consistent risk factors that enable the jump from suicidal ideation to suicide attempts. Underlying factors such as mood disorders may increase risk but require “additional precipitating events or conditions.”

Hopelessness and rumination are primary cognitive predictors; and hopelessness may be associated with recurrent self-harm. Depression is a major risk factor, as it is in the general population, but the cancer population is at higher baseline risk for depression, which has been linked to immunological changes.

 Identification and treatment of depression in cancer patients has been shown to decrease morbidity and mortality.

An important component of identifying at-risk patients is to determine the characteristics of those who historically have higher rates of suicide. As in the general population, the overall suicide rate in patients with cancer is linked to male gender, white race, lack of a partner and/or other social supports, and preexisting emotional or anxiety disorders as significant risk factors.

 In addition, older age, pain, advanced, disease, and poor prognosis are variables specific to this population that increase the risk of both suicidal ideations and suicide. Physical illnesses in general, particularly those associated with physical pain with consequent lifestyle limitations, are consistent risk factors that play a role in at least 25% of suicides, and the correlation increases with age.

 Patients with significant uncontrolled pain are at higher risk—thus a key component of cancer treatment must be adequate pain control. Minimal information has been collected on how substance use as reaction to a cancer diagnosis contributes to the risk of suicide. This may prove to be an important factor (

Although few thorough examinations of the methods typically used for suicide have been conducted, the National Cancer Institute 

 that overdose with painkillers and sedatives is the most common method of suicide used by cancer patients, and most of these occur at home.

 Despite this, screening for other methods of suicide (particularly firearms) should not be neglected.

A general understanding of suicidal ideation and behaviors involves alterations in the serotonin and HPA systems. The effects of a disease like cancer that alters immune system function can also alter these axes, which may result in increased risk of suicide. Independently of co-occurring cancer, the immune system is altered in depression (changes in cytokine and cell mediated immunity, changes in HPA axis) and may contribute to the development of depression in a reciprocal manner.

Depression secondary to medical causes should be ruled out in cancer patients. This typically includes an evaluation of B12 and folate levels, anemia, thyroid hormone imbalance, and adrenal hormone imbalance. The utility of assessing electrolyte abnormalities, including sodium, potassium, and magnesium remains unclear, although there is considerable interest in the effect of imbalances on mental health.

To further complicate this picture, several medications used to treat cancer have been linked to depression, such as corticosteroids, L-asparaginase, interferon-alpha, and amphotericin B.

Careful review of medication regimens and treatment alternatives may offer options for minimizing the effect of cancer therapy on mental health.

The “escape model” of suicidal drive may come into play, particularly in patients with a terminal diagnosis. This model postulates that the desire to escape from intolerable distress, combined with increased awareness of the factors contributing to that distress, leads to suicide.

 Accordingly, cancers with less than 5-year survival rates correlated to higher suicide risk, leading some to wonder whether the type of cancer is more important than the cancer diagnosis.

There are confusing data regarding the complicated mix of desire to speed up death, depression, hopelessness, and suicide risk. It appears that patients with baseline depression are more likely to want hastened death, expressing this desire up to 4 times as often, but Porta-Sales and colleagues

 found that simply discussing the wish for more rapid death did not cause distress, and that nearly 80% of patients felt it was an important topic for the care team to discuss.

Studies of suicidal ideation and completed suicide in adult cancer patients and survivors make up the bulk of the research in this area. As treatments and survival rates for childhood cancers improve, long-term studies of this population must include this information to more fully understand the lifelong effects of cancer treatment in children and adolescents, particularly since suicide is the top cause of death in the young adult populations of many developed countries. Gunnes and colleagues

 showed an increased risk of suicide in Norwegian patients aged 23 to 48 years who had a diagnosis of cancer before the age of 25. At exceptional risk were survivors of brain and testicular tumors, as well as leukemia. An American study did not replicate this finding but reported an increased risk of suicidal ideation compared with sibling controls.

 The average age of those who reported a first incident of suicidal ideation was 34 years, and they were, on average, 26 years past diagnosis. This is a serious example of how the sequelae of childhood cancer treatment can persist far into adulthood.

Is Refusal of Treatment a Form of Suicide?

Complicating the discussion of suicide in cancer patients is the subject of refusal of treatment. Is this considered suicide? Frenkel

 noted that “the unique patients who refuse conventional treatment are at times self-directed, confident, and active, and have thought deeply about the meaning of life and cancer and about their cancer treatment options.” What does it mean to have the ability to choose, to some extent, when we will die? This controversy has been taken all the way to the Supreme Court, with Justice Brandeis writing in Olmstead vs US that “the right to be left alone . . . the most comprehensive of rights and the right most valued by civilized men,” and Justice Burger clarifying that “nothing in this utterance suggests that Justice Brandeis thought an individual possessed their rights only as to sensible beliefs, valid thoughts, reasonable emotions.”

 Physicians are trained that the ultimate goal is to save or at least prolong life, but often neglected is the consideration of quality of life and patients’ desire to live, and die, in a manner they can, to some extent, control. Isenberg-Grzeda and colleagues

 reported on 3 patients who attempted suicide after being deemed ineligible for medical assistance in dying, further exemplifying the desire to have some say over the end of their lives.

Treatments can be quite similar to the treatment of depression in the general population, with psychotherapy and pharmacotherapy (selective serotonin reuptake inhibitors, selective serotonin-norepinephrine reuptake inhibitors, mirtazapine, trazodone) forming the basis. The most recent review of antidepressant therapy for depression in cancer patients did not show a significant improvement from placebo, but 

 noted that there were few studies from which to draw this information and noted that much more research is needed in this area.

Psychotherapy, no matter how brief, can help patients adjust to their new health circumstances and reassess their view of their life up until their diagnosis and goals going forward. In addition, special considerations such as the influence of altered immune activity and the effects of chemotherapy must also weigh into treatment decisions. Moreover, prescribers must be judicious in choosing medications that can be expected to show some positive effect within the patient’s expected lifetime, which may be significantly shortened. Stimulants may be useful in treating symptoms of fatigue and inattention that are common during cancer treatment. Close collaboration with the oncologic team can help to optimize mental health during cancer treatment.

Suicide and cancer are the top 10 causes of death in the adult population of the United States, and the world. Patients with cancer are at increased risk for both 

 and completed suicide. Factors contributing to this increase are both biological and psychological and components must be addressed in a timely fashion to increase quality of life. A refusal of treatment must not automatically be considered an instrument of suicide but viewed as a complex decision factoring in goals of care, particularly quality of life. More research is needed to determine how best to evaluate and treat oncology patients for suicidal thoughts and behaviors.

is faculty member, Department of Psychiatry, Albert Einstein Medical Center, Philadelphia, PA. The authors have nothing to disclose regarding this article.

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. Accessed July 14, 2020. https://www.who.int/news-room/fact-sheets/detail/cancer

14. McFarland DC, Walsh L, Napolitano S, et al. Suicide in patients with cancer: identifying the risk factors. 

3. Kumar V, Chaudhary N, Soni P, Jha P. Suicide rates in cancer patients in the current era in United States. 

4. Klaassen Z, Arora K, Wilson SN, et al. Decreasing suicide risk among patients with prostate cancer: implications for depression, erectile dysfunction, and suicidal ideation screening. 

5. Davies AD, Davies C, Delpo MC. Depression and anxiety in patients undergoing diagnostic investigations for head and neck cancers. 

6. Rahouma M, Kamel M, Abouarab A, et al. Lung cancer patients have the highest malignancy-associated suicide rate in USA: a population-based analysis. 

7. Urban D, Rao A, Bressel M, et al. Suicide in lung cancer: who is at risk? 

8. Simpson WG, Klaassen Z, Jen RP, et al. Analysis of suicide risk in patients with penile cancer and review of the literature. 

Suicide ideation in stomach cancer survivors and possible risk factors

10. Granek L, Nakash O, Ben-David M, et al. Oncologists,’ nurses,’ and social workers’ strategies and barriers to identifying suicide risk in cancer patients. 

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Antidepressants for the treatment of depression in people with cancer

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Clinical and epidemiological factors associated with suicide in colorectal cancer

32. Dalela D, Krishna N, Okwara J et al. Suicide and accidental deaths among patients with non-metastatic prostate cancer. 

33. Janes T. How can a suicide screening and prevention procedure be implemented in a cancer center? 

34. Anguiano L, Mayer DK, Piven ML et al. 

A literature review of suicide in cancer patients

Patients with cancer are at increased risk for both suicidal ideation and completed suicide. The authors discuss factors contributing to this increase in both biological and psychological realms.

Suicidal Ideation and Behaviors in Oncology Patients

Dr Drew Ramsey discusses the role of diet and nutrition in brain and mental health, promising areas of nutrition, and the importance of evidence-based treatment with food. Good nutrition is not a contest between zucchini and medications.



 is assistant clinical professor of psychiatry at Columbia University College of Physicians & Surgeons. His clinical work focuses on the treatment of depression and anxiety with a combination of psychotherapy, diet and lifestyle modification, and psychopharmacology. From 2005 to 2008, he directed the Audubon Continuing Day Treatment Program, a bi-lingual service for the severely mentally ill located in the Washington Heights area of Manhattan; a program of New York State Psychiatric Institute/Columbia Psychiatry.



is a board-certified psychiatrist and assistant professor in Clinical Psychiatry at Columbia University Medical Center and the New York State Psychiatric Institute. She serves as the medical director and team psychiatrist at ONTrackNY Washington Heights Community Service clinic. She completed her public psychiatry fellowship and adult psychiatry residency at Columbia University where she was a chief resident and co-organized the curriculum on racial/ethnic mental health disparities. In addition to her clinical work in the public sector, she also works in Columbia's psychiatric emergency room and has a private practice in Upper Manhattan. 

 is a fellow in consultation-liaison psychiatry at Columbia University Irving Medical Center with a part time private practice. She was formerly a chief resident at Columbia’s psychiatry residency program. Before medical training, she received an MS in Narrative Medicine, an interdisciplinary field that studies illness through a humanities lens. She is co-author of 

Conquering Lyme Disease: Science Bridges the Great Divide

 and has interests in medical education, psychotherapy, and medical humanities.

Thanks to Columbia University Department of Psychiatry for allowing us to present the Breakthrough Session podcast with experts in the field of psychiatry.

In this podcast, Drew Ramsey, MD, an nutritional expert and psychiatrist discusses the importance of diet and nutrition in mental health and wellness.

A Conversation With Drew Ramsey, MD, on Nutrition and Mental Health

Conversations in Critical Psychiatry is an interview series that explores critical and philosophical perspectives in psychiatry and engages with prominent commentators within and outside the profession who have made meaningful criticisms of the status quo.

 is the Theodore J. Castele Professor of the History of Medicine and Associate Director of the Program in Medicine, Society, and Culture at Case Western Reserve University, Cleveland, Ohio. He holds secondary appointments in the Departments of Bioethics and Psychiatry. He earned degrees in history from Wesleyan (BA), Stanford (MA), and Johns Hopkins University (PhD); he also studied psychiatric epidemiology at Columbia University. He is the author of 

Imperial Bedlam: Institutions of Madness and Colonialism in Southwest Nigeria

 (University of California Press; 1999); 

Electroconvulsive Therapy in America: The Anatomy of a Medical Controversy

 (Polity Books; 2020). His articles have appeared in journals including the

 Journal of the History of Medicine and Allied Sciences, Harvard Review of Psychiatry, Bulletin of the History of Medicine

Dr Sadowsky is a leading historian of psychiatry, and one I am proud to call him my teacher. As a psychiatry resident, I attended his lectures on history of psychiatry as part of our residency didactics and benefitted greatly from them. Sadowsky was 

 in 2017 by Greg Eghigian, PhD, about his book, 

, an interview that is well worth revisiting. The present interview is about his new book 

. I admire Sadowsky for his ability to tackle complex and controversial issues with scholarly rigor and fair-minded appraisal, and I am delighted to have him participate in this series.

 Before I jump into my questions, I want to give you an opportunity to introduce your book to the readers on your own terms. What are the issues that occupy you? I suppose some folks on hearing about 

 may reflexively think, “What… another book about depression? Don’t we have enough of those already?” Perhaps in your response you can also touch on why a new history of depression was needed in your opinion.

 First, not many of the books about depression are histories. Take 

The story of depression, through time and around the world. 

Major Depressive Disorder

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A Conversation With Drew Ramsey, MD, on Nutrition and Mental Health

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