Hero

Videos

Slideshows

Articles

Podcasts

Poll

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.

1. Centers for Disease Control and Prevention. National Health Report Highlights. Accessed July 14, 2020. https://www.cdc.gov/healthreport/publications/compendium.pdf

. 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. 

11. Spoletini I, Gianni W, Caltagirone C, et al. Suicide and cancer: where do we go from here? 

12. Li C, Li C, Forsythe L, et al. Mental health services utilization and expenditures associated with cancer survivorship in the United States. 

13. Sherrill C, Smith M, Mascoe C, et al. Effect of treating depressive disorders on mortality of cancer patients. 

15. Abourmrad M, Shiner B, Riblet N, et al. Factors contributing to cancer-related suicide: a study of root-cause analysis. P

16. National Cancer Institute. Depression (PDQ®). . Accessed July 14, 2020. https://www.cancer.gov/about-cancer/coping/feelings/depression-pdq

17. Kenna HA, Poon AW, de los Angeles CP, et al. Psychiatric complications of treatment with corticosteroids: review with case report. 

18. Celano CM, Freudenreich O, Fernandez-Robles C, et al. Depressogenic effects of medications: a review. 

19. Pinto EF, Andrade C. Interferon-related depression: a primer on mechanisms, treatment, and prevention of a common clinical problem. 

20. Weddington WW. Delirium and depression associated with amphotericin B. 

21. Baumeister RF. Suicide as escape from self. 

22. Porta-Sales J, Crespo I, Monforte-Royo C, et al. The clinical evaluation of the wish to hasten death is not upsetting for advanced cancer patients: a cross sectional study. 

23. Gunnes MW, Lie RT, Bjorge T, et al. Suicide and violent deaths in survivors of cancer in childhood, adolescence, and young adulthood: a national cohort study. 

24. Brinkmann TM, Zhang N, Recklitis CJ, et al. Suicide ideation and associated mortality in adult survivors of childhood cancer. 

27. Isenberg-Grzeda E, Bean S, Cohen C, et al. Suicide attempt after determination of ineligibility for assisted death: a case series. 

28. Ostuzzi G, Matcham F, Daughy S, et al. 

Antidepressants for the treatment of depression in people with cancer

29. Zaorsky NG, Zhang Y, Tuanquin L, et al. Suicide among cancer patients. 

30. Al-Ghazal SK, Fallowfield L, Blamey RW. Comparison of psychological aspects and patient satisfaction following breast conserving surgery, simple mastectomy and breast reconstruction. 

31. Pham TT, Talukder AM, Walsh NJ, et al. 

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

Brendan Dunlop talks about the self-harm risks and nuanced needs of bisexual individuals. For updates on the study, follow them on Twitter 

 is a clinical psychologist in training  at the University of Manchester, UK, and co-investigator on the Self-Injury in Young Bisexual People - a Longitudinal Investigation (SIBL) study. 

Bisexual individuals are at 4.5 to 6 higher risk of self harming than heterosexual individuals, according to this online study. 

Risky Business: The Higher Risk of Nonsuicidal Self Injury in Bisexual Individuals

Susan J. Noonan, MD, MPH, talks about signs of suicide and how to help the person in need. 

is a physician consultant and Certified Peer Specialist in the Department of Psychiatry at McLean Hospital and the Massachusetts General Hospital. She is the author of four books and a blog on managing depression, most recently 

Helping Others With Depression: Words to Say, Things to Do (December 2020)

. Dr Noonan offers peer counseling to fellow patients, including physicians and other professionals, and can be confidentially reached through her website at 

When deep, emotional pain exceeds logic, suicidal thoughts come to fruition. 

Wayward Thoughts

H. Steven Moffic talks about the alarming suicide rates, specifically that of police officers. While police need to be held accountable for potential racism and bias, they also are in need of mental health support, as are many at this time. 

is an award-winning psychiatrist who has specialized in the cultural and ethical aspects of psychiatry. A prolific writer and speaker, he received the one-time designation of being a Hero of Public Psychiatry from the Assembly of the American Psychiatric Association in 2002. He has recently been leading Tikkun Olam advocacy movements on climate instability, burnout, Islamophobia, and anti-Semitism for a better world. He serves on the Editorial Board of

A time that should be full of happy events has turned sour. 

Suicide, Psychiatry, and Politics

FROM THE ACADEMY OF CONSULTATION-LIAISON PSYCHIATRY

Somatic symptom and related disorders (SSRDs) are a set of psychiatric conditions characterized by physical symptoms that are inconsistent with physical disease and influenced by psychological factors. They are common in pediatric medicine, with prevalence rates ranging from 13% to 50% depending on the setting. Across all ages, SSRDs account for nearly 20% of health care spending annually.

 Additionally, a small subset of patients have multiple somatic complaints and tend to access crisis and emergency services and hospital services at higher rates. They also have high recidivism rates.

Despite the recognition of the impact of SSRDs on pediatric health care, clinicians and patients/families continue to be frustrated with the evaluation and management of these conditions.

 Without early incorporation of a broader biopsychosocial conceptualization, there can be an undue focus on disability, impairment, and somatic complaints. This leads to low-yield diagnostic testing and increased polypharmacy interventions that do not address the rehabilitative needs of the patient and family.

 In the absence of an explanatory model for symptoms, patients and families may feel they are being dismissed, creating a dynamic of mistrust between patients/families and the medical system. Ultimately, without a clear road map for evaluation and management, care can be inconsistent and misuse of health care resources may occur, which, in turn, can lead to poor outcomes.

As SSRDs most often present in nonpsychiatric settings, a patient’s first contact with a mental health care provider may be through psychiatric consultation in the emergency department or in a hospital setting. Therefore, psychiatric consultation should be considered as early as possible to foster the perception that consultation-liaison (CL) psychiatrists are an integral part of the multispecialty team.

SSRDs account for approximately 15% to 20% of psychiatric consults in the pediatric hospital setting and have been reported as the second most common reason for consultation after suicide assessments.

 As such, there is a growing effort to standardize the evaluation and management of pediatric SSRDs. Most recently, the 

American Academy of Child and Adolescent Psychiatry 

(AACAP) published a Clinical Consensus Pathway for SSRD Evaluation and Management.

Most SSRDs are seen in nonpsychiatric settings, with approximately 6% of hospitalized children relaying symptoms consistent with an SSRD.

 The most common complaints include neurologic symptoms, pain, gastrointestinal distress, and fatigue.

 SSRDs can present at any age, but they are more common and less problematic in prepubertal youth, with increasing impairment and pathology in adolescents.

 Prevalence rates are equal across sexes prior to puberty; after puberty, higher prevalence is seen in female sex.

 Although psychological trauma, particularly sexual trauma, is a well-associated risk factor for SSRDs in adults, it is not necessarily associated with SSRDs in youth.

 However, if present, trauma in youth with SSRDs often results in a more complicated treatment course, more severe symptoms, and increased risk for need of higher levels of psychiatric care.

The evaluation and management of youth experiencing an SSRD are predicated on early recognition of risk factors (

). The foundation of an SSRD evaluation is built on concurrent mental health and physical health evaluation, unified evidence-based language that is consistent across disciplines, and direct communication with the family regarding the multifactorial nature of SSRD presentation. Care of youth with SSRDs requires close interprofessional team support. This includes collaboration among the primary care physician (PCP), emergency physician, hospitalist physician, nursing, social work, child life, rehabilitative staff, subspecialty pediatricians, and CL psychiatrist/psychologist. Roles should be delineated early in the management course.

CL psychology/psychiatry should be consulted at the earliest suspicion of an SSRD to normalize psychiatric involvement in comprehensive care. Beyond assessment, CL psychology/psychiatry can aid with framing conversations with the patient and family, providing evidence-based interventions, and addressing psychiatric comorbidities. Although SSRDs do not necessarily accompany other discrete psychiatric conditions, anxiety disorders and mood disorders may be present in up to 50% of youth with SSRDs. These comorbidities should be incorporated in the case formulation for proper management of these conditions.

 Ultimately, this process is dynamic and highly interactive and should adapt to the needs of the patient and family.

Discussion of symptom development and diagnostic conceptualization should be paired with management strategies, highlighting the multifactorial contributors to symptom development. Pairing the multiple biopsychosocial factors allows for a coherent, systematic approach to rehabilitative care, psychotherapeutic management, and judicious use of targeted psychopharmacology. Joint communication by all involved physicians and other clinicians using consistent DSM-5 language and clear discussions of a conceptual framework for symptom development, highlighting mind-body interactions, are crucial.

Once the evaluation is complete and the diagnosis of SSRD is confirmed, it is helpful to have an interprofessional care meeting with the patient family to share the diagnosis. Explaining a conceptualization of how symptoms formed, progressed, and continue to present—along with the related biopsychosocial factors influencing presentation—is the most critical part of this conversation. This is accomplished via joint physical health and mental health providers using consistent DSM language with the relationship of physical, environmental, psychological, social, and cognitive factors to symptom development. For the patient and family to invest in the diagnoses and partner in the ongoing management of SSRD, they must understand this conceptualization.

Importantly, clinicians should gauge the patient’s and family’s readiness to accept the information. As such, communication must be geared to the individual’s understanding, values, and readiness. It is often valuable to pair discussions with the use of motivational interviewing to enhance engagement and understand the patient’s or family member’s experience. Discussions may start with a more biological conceptualization, emphasizing concepts such as somatosensory amplification and visceral hypersensitivity; analogies may be used to highlight mind-body interactions. Some families may be able to appreciate and incorporate psychological constructs earlier in the discussion of this conceptual framework. It is important to validate emotions while shifting discussions to functionality. Patients may want to focus on their impairment; it is, therefore, important to pivot conversation to highlight strengths, abilities, and incremental improvements.

Management of an SSRD in youth is an iterative process that begins with setting clear goals and expectations. Misalignment of expectations is often a point of conflict. Patients and families may expect complete resolution of symptoms following initial encounters. Here, psychoeducation is key to the initial framing of the concept of somatization, discussing mind-body interactions, and describing joint medical and psychiatric management. Cognitive behavioral therapy (CBT) has a strong evidence base in addressing psychological factors underpinning pediatric SSRD.

 CBT aids in greater awareness of how cognition, emotions, and other psychological processes impact physical sensations, and it empowers the patient with strategies to dampen somatic complaints. It focuses on improving functioning in small, achievable steps while shifting the focus away from impairment.

CBT psychotherapy can occur in tandem with delivery of rehabilitative services. As many as 50% of youth with an SSRD will have a comorbid depressive or anxiety disorder, making treatment of psychiatric comorbidities an important component of SSRD management.

 Close involvement with the PCP is necessary, including proactive, regularly scheduled brief visits. These visits should be used to coordinate services, address questions, monitor progress, provide reassurance, and promote functioning. PCPs should conduct judicious evaluations of new concerns, collaborating with psychiatry, psychology, and subspecialty pediatrics as needed. In this way, the propensity to seek care in crisis and pursue care in a disjointed fashion can be extinguished over time.

Care should be provided in the setting that best matches the patient’s needs and severity of illness. For youth with severe worsening of function without a clear diagnostic understanding, medical admission may be warranted for further evaluation and management. Youth with significant psychiatric comorbidity may benefit from inpatient or partial psychiatric hospitalization. Those patients with significant rehabilitative needs will benefit from intensive outpatient or inpatient rehabilitation. Most youth, however, can be successfully managed in the outpatient setting with regular PCP evaluations, ongoing psychotherapy, and psychiatric care, as well as additional rehabilitative and pediatric subspecialty follow-up.1 This approach, which aligns with national consensus, provides the best framework for youth to regain functioning, improve symptomatically, and succeed in the care of SSRD.

Care of youth with SSRDs highlights the important liaison role of CL psychiatry. CL psychiatrists aid in the dissemination of information and develop a shared understanding with the patient and family; they also support appropriate language use and incorporate psychological, social, psychiatric, familial, and cognitive factors in the overall assessment with the larger care team. This should include clearly defining care team roles, as well as setting expectations with patients and their families (

The CL psychiatrist should describe mind-body interactions using analogies that simplify understanding for the patient and family. For example, a computer analogy helps explain SSRDs, in which physical disease is more akin to a hardware problem and psychosocial and environmental factors are more akin to a software issue. Similarly, it can be helpful to describe SSRDs as the body’s alarm system being overactive or hypersensitive to somatosensory interactions, which can lead to identification of factors that can heighten or dampen normative reactions to bodily sensations. The goal is to aid patients and families in understanding the interplay of physiologic, psychological, social, and emotional factors that influence somatic symptoms.

Given the diverse and wide-ranging issues and the number of team members involved in effective SSRD care, the CL psychiatrist should also be at the forefront in aiding standardization of multidisciplinary, evidence-based interventions. This should be informed by existing consensus guidelines, such as those published by the AACAP in 2020, and local resources, systems of care, and practice experiences.

CL psychiatrists may be asked about the use of psychopharmacology in managing SSRDs. There is no evidence to demonstrate that psychopharmacology can directly ameliorate the symptoms of SSRDs, and this should be expressed clearly to patients and families as well as to the larger care team.14 At times, youth and families may become frustrated that psychopharmacology has not resulted in resolution of symptoms. Therefore, it is important to reiterate, early on, that management of SSRDs is predicated on a multidisciplinary approach that targets the factors fostering symptom-development and persistence. Here the focus is shifted to improvement in functioning and incremental rehabilitation of cognitive, emotional, and physical health factors.

Psychopharmacology can be helpful in addressing psychiatric comorbidities and may provide more immediate relief for other psychiatric factors resulting in acute distress. When provided, psychopharmacological options should have clear targets for management with clear expectations within the greater context of treatment. It is important to explore familial expectations and continue to set realistic expectations, emphasizing the importance of ongoing engagement with other care teams, including psychology and rehabilitative services.

CL psychiatry can also have an important role in informing longitudinal management of SSRDs, which may be accomplished through collaborative clinical models. Such models often have psychiatry and psychology providing integrated care in a primary care or subspecialty pediatric practice. Inpatient psychiatric care may be needed for young patients with severe psychiatric comorbidities, safety concerns related to suicidal ideation or behavior, or severe psychological trauma. Ultimately, disposition planning must account for the level of training, experience, resources, and standardization of practice that exists within different settings in a given health system.

 is a child and adolescent psychiatry fellow at the University of Michigan. Dr Biermann is clinical assistant professor in the Department of Psychiatry at the University of Michigan.

is a clinical instructor and associate medical director of the Nyman Family Unit in the Department of Psychiatry at the University of Michigan. 

is associate professor in the Departments of Psychiatry and Pediatrics at the University of Michigan.

1. Malas N, Donohue L, Cook RJ, et al. Pediatric somatic symptom and related disorders: primary care provider perspectives. 

2. Kullgren KA, Shefler A, Malas N, et al. Taking the pain out of somatization: development and implementation of a hospital-based clinical practice guideline to address pediatric somatic symptom and related disorders. 

3. Ibeziako P, Brahmbhatt K, Chapman A, et al S. Developing a clinical pathway for somatic symptom and related disorders in pediatric hospital settings. 

4. Shaw RJ, Pao M, Holland JE, DeMaso DR. Practice patterns revisited in pediatric psychosomatic medicine. 

5. Bujoreanu S, White MT, Gerber B, Ibeziako P. Effect of timing of psychiatry consultation on length of pediatric hospitalization and hospital charges. 

6. Ibeziako P, Bujoreanu S. Approach to psychosomatic illness in adolescents. 

7. Rask CU. Functional somatic symptoms in 5-7 year old children: assessment, prevalence and co-occurrence. 

8. Jones GT, Silman AJ, Power C, Macfarlane GJ. Are common symptoms in childhood associated with chronic widespread body pain in adulthood? results from the 1958 British Birth Cohort Study. 

9. Malas N, Ortiz-Aguayo R, Giles L, Ibeziako P. Pediatric somatic symptom disorders. 

10. Plioplys S, Doss J, Siddarth P, et al. Risk factors for comorbid psychopathology in youth with psychogenic nonepileptic seizures. 

11. Thomson K, Randall E, Ibeziako P, Bujoreanu IS. Somatoform disorders and trauma in medically-admitted children, adolescents, and young adults: prevalence rates and psychosocial characteristics. 

12. Liu J, Gill NS, Teodorczuk A, et al. The efficacy of cognitive behavioral therapy in somatoform disorders and medically unexplained physical symptoms: a meta-analysis of randomized controlled trials. 

13. Ibeziako P, Randall E, Vassilopoulos A, et al. Prevalence, patterns, and correlates of pain in medically hospitalized pediatric patients with somatic symptom and related disorders. 

14. Kleinstäuber M, Witthöft M, Steffanowski A, et al. Pharmacological interventions for somatoform disorders in adults. 

There is a growing effort to standardize the evaluation and management of pediatric SSRDs, which have been reported as the second most common reason for consultation after suicide assessments.

Care of Youth Hospitalized With Somatic Symptom and Related Disorders

In the wake of the coronavirus pandemic 2019, physicians and trainees are facing new types of stressors. In a profession where burnout and depression are already commonplace, these additional stressors and traumas can prove overwhelming. Many physicians may need and want to seek psychiatric care but feel unable to do so due to fear of professional repercussions.

The consequences are tragic. The story of 

, MD, the New York City physician who died by suicide at the start of the pandemic is, lamentably, not unique.

 Only a month into 2021, there are already multiple reports of physicians and medical students dying by suicide. Approximately 300 to 400 physicians die by suicide each year, 

Suicide is largely associated with untreated or undertreated psychiatric illness.

, treatment for psychiatric disorders is generally low due to various barriers to care, including inadequate access, self-denial of symptoms, and stigma.

 Physician populations seeking treatment face additional barriers to care. Fear of the 

 if they are known to be receiving psychiatric care can play a major role in their avoidance of care.

Although stigma toward psychiatric conditions in medicine has decreased, it remains a real problem. A recent 

 confirms the fears of those who worry about revealing their illnesses.

 When residency applications disclosed a common psychiatric illness (major depressive disorder), they were at a notable disadvantage when compared to applicants who disclosed non-psychiatric illness (diabetes mellitus type 1). This is just a single example of the many systems within medicine that still perpetuate stigma surrounding psychiatric disorders. Given the very real, often punitive impacts to receiving psychiatric care, it is not surprising that so many physicians chose to stay silent, which can have dire consequences.

 do not ask about mental health conditions, or only ask about current impairment.

 But other states inquire into applicants’ psychiatric history, asking questions related to current functioning and 

 about diagnoses or treatments in the past.

 Furthermore, disclosure of treatable and common conditions such as anxiety or depression may result in a 

 Physicians working in states with more in-depth questions about psychiatric diagnoses are 20% less likely to seek treatment.

 This silence can lead to deadly consequences, quite literally putting the physicians’ life in jeopardy.

 despite current attempts to improve trainee wellness.

 now make explicit efforts to ensure mental wellbeing of their students.

 When students enter medical school the administration does its due diligence by providing links to resources for 

 and advising students to seek help when needed.

 Regrettably, even now after all of these positive changes, 

medical students are still 3 times more likely than their peers to die by suicide

 report having suicidal thoughts in the past 2 weeks.

The process of seeking help for a psychiatric issue can be daunting for anyone. For potential patients, there are often guides online providing step-by-step information about what the process of seeking help looks like. Unfortunately, this process can be different for those in the medical profession. They learn about psychiatric care through rumors or whisper networks. Fear motivates most to stay quiet, and this silence continues after medical school. 

 of physicians have found that almost 50% believe they met DSM criteria for a psychiatric diagnosis but refuse to seek treatment, largely due to concerns relating to stigma and repercussions of licensing boards.

 released in October 2020 showed that many physicians still do not feel comfortable seeking mental health treatment, even in light of the additional stress of COVID-19. More than half (57%) reported concerns for their jobs if they were to seek help, and 73% believed that there was still significant stigma in the workplace towards those with psychiatric disorders, stating that this stigma played a role in their avoidance of the care they believed they needed.

It is clear that the current system leads physicians and trainees to avoid 

 While the system may prevent some from seeking care, the benefits from seeking treatment do outweigh these risks in a majority of cases. Last year, hundreds of physicians spoke out on social media about their own pathways to treatment, many stating that they wished they had sought treatment earlier.

 These testimonials prove that although seeking treatment for a psychiatric condition may be more professionally burdensome than it should be, it does not end careers—for most. In fact, by seeking treatment many of these physicians stated that it improved their ability as physicians.

Physicians should never be penalized for seeking help. Nonetheless, while we work to further improve the system it is important that medical training also includes education about how and when to get treatment. Both trainees and their supervisors should understand this process. Physicians who do not need to seek psychiatric help are often not aware of these processes and their implications; however, trainees are all taught about the importance of reporting physicians who appeared impaired. Providing clear information on how to seek treatment and demystifying concerns surrounding the professional impacts of treatment allows individuals to seek help early, rather than creating a situation where we must wait to catch our colleagues at their lowest points before they submit to treatment.

There is no doubt that more physicians would seek psychiatric care if non-punitive, non-stigmatizing policies were in place. Fortunately, 

More than half of physicians believe that seeking psychiatric care would jeopardize their employment. What can be done? 

Suicide

Suicidal Ideation and Behaviors in Oncology Patients

Risky Business: The Higher Risk of Nonsuicidal Self Injury in Bisexual Individuals

Wayward Thoughts

Suicide, Psychiatry, and Politics

Care of Youth Hospitalized With Somatic Symptom and Related Disorders

Stigma in Healthcare: Empowering Physicians and Trainees to Seek Help

Beneath the Wheel: A Resident Reflects on Burnout and Professional Identity

The Promise and Potential of Emergency Psychiatry

The Field as a Master Class in Interviewing

CAHOOTS: A Model for Prehospital Mental Health Crisis Intervention