In 2013, in the United States, more than 41,000 people died from suicide and more than 650,000 suicide attempts required treatment at an emergency department.1 Although suicide is the 10th leading cause of death in the United States for all age groups,1 suicidal death may not generate appropriate public awareness. For example, media reports and family member accounts are less likely to share details regarding suicide out of both respect for the bereaved and religious connotations that exist within society.2,3

Suicide prevention represents a unique challenge for health care providers. Many of those who commit suicide have a physical illness that may contribute to suicidal ideation, and reports suggest that a cancer diagnosis doubles suicide rates.4 Our study in the current issue of Journal of Wound, Ostomy and Continence Nursing specifically delineated the impact of radical cystectomy on suicidal death in patients with bladder cancer. We found there was a trend toward increased suicide rates in all age groups, with the greatest risk in patients older than 70 years. The impact of age and suicide in these patients is important when you consider that both suicide and bladder cancer are more prevalent in older patients. Patients with bladder cancer were also found to have an increased risk of suicide at any time after diagnosis, highlighting the morbidity associated with intervention and potential psychological distress associated with disease surveillance and follow-up. Other demographic factors associated with an increased risk of suicide for patients with bladder cancer included white race, male gender, and single marital status.

Of particular interest to WOC nurses, we found that patients with bladder cancer who underwent radical cystectomy were at higher risk for suicide compared to patients who did not undergo surgical intervention. In addition to the stress of a cancer diagnosis, patients who require a radical cystectomy often undergo weeks of neoadjuvant chemotherapy. Furthermore, radical cystectomy patients will have concomitant urinary diversion that their daily habits, whether the urinary diversion is an orthotopic neobladder, continent cutaneous diversion, or ileal conduit. WOC nurses have an influential role in the lives of patients with a urostomy. The majority of patients feel that WOC nursing care and ostomy education is important perioperatively and during the years after urinary diversion.5 Patients with urostomies often take several months before they feel comfortable managing their care and diet on a daily basis.6 The amount of time and the nature of care that WOC nurses have with patients afford them an important position to assess a patient's suicide risk and overall mental health status.

One of the limitations of our study is that our data did not assess suicide attempts, suicidal ideation, or overall mental health in patients with bladder cancer. Of interest, several surveys of patients with bladder cancer who received a urostomy failed to detect long-term psychological or mental health issues compared to the general population.7-10 However, quality-of-life assessments have demonstrated that patients complain of physiological and sexual dysfunction related to radical cystectomy and urinary diversion, and almost half of patients report having feelings of depression following surgery.6,11

All healthcare providers have a responsibility to patients to be aware of suicide risks and warning signs for depression and withdrawn psyche. Assessing patients for depression and/or suicidal risk at preoperative appointments and during the rigorous bladder cancer surveillance follow-up appointments requires an index of suspicion and awareness of a patient's mental stability. This may entail having direct and honest conversations with patients about their mood and feelings, which admittedly may be difficult for healthcare providers. These conversations may become easier when we develop a personal comfort level discussing these topics in addition to developing long-term, trusting, and therapeutic relationships with our patients. WOC nurses are an integral part of the healthcare team and have the opportunity to work with bladder cancer patients during one of the most stressful and difficult transitions of their life. Important components of this relationship includes educating patients on proper ostomy care technique, assisting in obtaining and ordering ostomy supplies for home use, providing an avenue for communication, and assessing symptoms of depression that may not be communicated to the physician. Secondary to the long-term risk of suicide for patients with bladder cancer, developing an extended depression and suicidal ideation screening protocol is appropriate.12 This information may be useful for clinicians counseling patients with bladder cancer pre- and post-radical cystectomy, as well as with screening for emotional distress and depression after surgery. A multidisciplinary approach and a low threshold for involvement of mental healthcare providers are important for providing well-rounded care for our bladder cancer patients.

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