Suicidal Ideation Experienced by Long-Term Survivors of Blood or Marrow Transplantation: A Blood or Marrow Transplant Survivor Study Report.

Suicidal Ideation experienced by long-term survivors of Blood or Marrow Transplantation: a BMTSS Report - PMC Skip to main content An official website of the United States government Here's how you know Here's how you know Search Log in Primary site navigation Search Log in Search PMC Full-Text Archive Search in PMC Journal List User Guide As a library, NLM provides access to scientific literature. Inclusion in an NLM database does not imply endorsement of, or agreement with, the contents by NLM or the National Institutes of Health. Learn more: PMC Disclaimer | PMC Copyright Notice Transplant Cell Ther . Author manuscript; available in PMC: 2026 Jun 3. Published in final edited form as: Transplant Cell Ther. 2026 May 5;32(9):1142.e1–1142.e11. doi: 10.1016/j.jtct.2026.04.051 Suicidal Ideation experienced by long-term survivors of Blood or Marrow Transplantation: a BMTSS Report Ritika Samant 1 , Devika Bhatia 2 , Qingrui Meng 1 , Yanjun Chen 1 , Lindsey Hageman 1 , Liton Francisco 1 , Sarah Palmer 1 , Eunice Choe 1 , Nora Balas 1 , Alysia Bosworth 3 , Ravi Bhatia 1 , F Lennie Wong 3 , Daniel J Weisdorf 4 , Wendy Landier 1 , Saro H Armenian 3 , Smita Bhatia 1 Author information Article notes Copyright and License information 1 University of Alabama at Birmingham, Birmingham, Alabama, USA; 2 University of Colorado, Denver, Colorado; 3 City of Hope, Duarte, California, USA; 4 University of Minnesota, Minneapolis, Minnesota Contributions S.B., S.A., D.W. contributed to study conception and design. S.B., A.B., S.A., L.H., S.P., E.C., collected and assembled the data. Q.M., R.S., and S.B. analyzed and interpreted the data. R.S., D.B., and S.B. drafted the manuscript. All authors critically reviewed the manuscript for important intellectual content and approved the final manuscript. S.B., S.A., A.B., L.H., D.W., W.L., provided administrative, technical, or material support. S.B. supervised the study. ✉ Correspondence: Smita Bhatia, MD, MPH, 1600 7 th Avenue South, Lowder 500, Birmingham, AL 35233; Fax: 205-638-2121; smitabhatia@uabmc.edu Issue date 2026 Sep. PMC Copyright notice PMCID: PMC13228513  NIHMSID: NIHMS2180454  PMID: 42092581 The publisher's version of this article is available at Transplant Cell Ther Abstract High-intensity therapeutic exposures and prolonged immune suppression place blood or marrow transplant (BMT) survivors at a high risk of long-term physical and psychological morbidity that could lead to suicidal ideation. We examined suicidal ideation in BMT survivors who received autologous or allogeneic BMT between 1974 and 2014 at one of three transplant programs and survived ≥2y after BMT. Overall, 3 841 BMT survivors and 1 261 siblings who completed a 255-item survey at age ≥18y were included. The survey assesses sociodemographics, chronic health conditions, and psychological health. BMT survivors were at a 1.9-fold greater odds of experiencing suicidal ideation compared with siblings (95%CI=1.34–2.68). Multivariable analysis adjusting for age at survey, sex, income, insurance, marital status, severe/life-threatening chronic health conditions, pain, anxiety, and depression, mitigated the difference in suicidal ideation between BMT survivors and siblings (OR=0.97; 95%CI=0.65–1.44). Restricting the analysis to BMT survivors, we found that, male sex (OR=1.38, 95%CI=1.02–1.87), being divorced (OR=1.74, 95%CI=1.13–2.67; reference: married), presence of anxiety (OR=2.32, 95%CI=1.66–3.26), and presence of both pain and depression (OR=10.67, 95%CI=6.71–16.97; reference: no depression or pain) were associated with suicidal ideation. These findings suggest a need for increased surveillance and intervention for suicidal ideation among at-risk BMT survivors. INTRODUCTION Blood or marrow transplantation (BMT) is an established therapeutic option for patients with hematologic malignancies and other life-threatening illnesses. In the US, over 22 000 individuals receive a BMT every year. 1 While improvement in transplantation strategies and supportive care have resulted in a decline in mortality, BMT recipients carry a significant burden of late-occurring morbidity, placing them at high risk for impairments in mental health, including anxiety and depression that could potentially lead to suicidal ideation. 2 – 4 The risk of suicidal ideation is elevated in conventionally-treated cancer patients when compared with the general population. 5 , 6 Anxiety, depression, pain, and lack of social support are associated with suicidal ideation among the conventionally-treat cancer patients. 7 – 9 A previous study from the European Group for Blood and Marrow Transplantation Registry found a two-fold greater risk of death from suicides among BMT recipients as compared with the European general population; this study did not examine suicidal ideation. 10 Given the high burden of physical and psychological morbidity borne by BMT survivors, 2 – 4 there is a need to understand the prevalence and predictors of suicidal ideation among long-term BMT survivors, such that anticipatory guidance and support can be provided to those at highest risk. We leveraged the BMT Survivor Study (BMTSS) to address these gaps in knowledge. METHODS BMTSS is a retrospective cohort study with prospective longitudinal follow-up. The overarching goal of BMTSS is to examine the long-term outcomes of individuals who survived two or more years after BMT performed between 1974 and 2014 at the University of Alabama at Birmingham (UAB), City of Hope (COH) or University of Minnesota (UMN). The BMT survivors who agreed to participate were asked to nominate siblings who would be willing to participate and provide their contact information. These siblings were invited to participate and constituted the non-transplant comparison population. BMT recipients and the sibling cohort completed the BMTSS survey that captures the following: sociodemographic characteristics (race/ethnicity, annual household income, and health insurance), chronic graft vs. host disease (cGvHD), health behaviors, and chronic health conditions as diagnosed by the participants’ healthcare providers. Chronic health conditions were graded using the Common Terminology Criteria for Adverse Events 11 , v5.0 based on their severity: mild (grade 1), moderate (grade 2), severe (grade 3), or life-threatening (grade 4). The survey captures details regarding the survivors’ mental health using the Brief Symptom Inventory-18 (BSI-18). 12 BSI assesses depression and anxiety via the following prompts: “Describe how much the problem listed below has distressed or bothered you during the past 7 days including today: [depression assessment] (i) feeling lonely; (ii) feeling blue; (iii) feeling no interest in things; [anxiety assessment] (i) feeling nervous; (ii) feeling suddenly scared; (iii) feeling fearful; (iv) feeling numbness or tingling; (v) feeling panic; (vi) feeling restless”. Participants responded on a 5-point Likert scale from “not at all” to “extremely”. Participants responding “moderately”, “quite a bit”, or extremely” to any of these questions were classified as depressed or anxious for this study. Survivors’ age at BMT, sex, primary diagnosis (indication for BMT), type of transplant (autologous; allogeneic), stem cell source (bone marrow, peripheral blood stem cells [PBSCs] or cord blood), risk of relapse at BMT (standard risk; high risk), and conditioning regimen were retrieved from institutional transplant databases and/or participants’ medical records. The Institutional Review Board (IRB) at UAB served as the single IRB of record and approved the study. Participants provided informed consent according to the Declaration of Helsinki. The current report included study participants who had completed the BMTSS survey at age 18 or older, regardless of the age of transplantation ( Figure 1 ). Differences between study participants and non-participants are shown in Supplemental Table 1 . Participants were older at BMT, more likely to be females, non-Hispanic White, and more likely to have received BMT for acute myeloid leukemia/myelodysplastic syndrome (AML/MDS), chronic myeloid leukemia (CML), non-Hodgkin lymphoma (NHL) and plasma cell dyscrasias (PCD). They were also more likely to have received autologous BMT. Figure 1: Open in a new tab Consort Diagram Outcome The primary outcome of interest was suicidal ideation queried in the BSI: “ How much has the following problem distressed you or bothered you during the past 7 days: Thoughts of ending your life ”. Participants respond on a 5-point Likert scale from “not at all” to “extremely”. All responses consisting of “Moderately”, “Quite a bit” or “Extremely” were considered to indicate suicidal ideation. Statistical Analyses All analyses were performed using SAS v9.4 (SAS Institute, Cary, North Carolina). Two-sided tests were considered statistically significant at P <.05. Descriptive statistics were reported using mean (standard deviation), median (range), or counts (percentages) as appropriate. Logistic regression was used to determine the odds of suicidal ideation among survivors when compared with the sibling cohort, starting with a bivariate comparison (Model 1), then adjusting for sociodemographics (age at survey completion, sex, race/ethnicity, annual household income, health insurance) (Model 2), and then adding each of the following variables individually to Model 2: marital status (Model 3), pain (Model 4), presence of severe or life-threatening chronic health conditions (grade 3–4) (Model 5), depression (Model 6), and anxiety (Model 7). In the final multivariable model (Model 8), we examined the odds suicidal ideation among BMT survivors vs. the sibling cohort adjusting for all the above variables simultaneously. We also examined factors associated with suicidal ideation among BMT survivors by using logistic regression and adjusting for clinical and demographic factors using backward selection. The following variables were examined for their possible inclusion in the model: age at BMT, sex, race/ethnicity, annual household income, health insurance, marital status, primary diagnosis, disease status at BMT, BMT type, cGvHD, stem cell source, conditioning intensity, exposure to conditioning agents including total body irradiation (TBI), grade 3–4 chronic health conditions, presence of anxiety, depression and pain, time from BMT to survey completion, and BMT site. RESULTS Participant Characteristics Table 1 shows the demographic and clinical characteristics of the 3 841 BMT survivors who were included in this analysis. The indications for BMT included NHL (24.5%), AML/MDS (23.3%), PCD (17.9%), CML (10.0%), acute lymphoblastic leukemia (ALL; 8.4%), Hodgkin lymphoma (HL; 8.0%), and other diagnoses (7.9%). Overall, 53.1% of the survivors received allogeneic BMT, and of these, 55.3% carried a history of cGvHD. PBSCs served as a stem cell source in 66.7% of the survivors. TBI was used for conditioning in 48.6% of the survivors. Median age at BMT was 45 years (y) (range: 0–74) and at survey completion was 56y (18–83). Fifty-five percent of the cohort was male and 74.4% identified themselves as non-Hispanic-White. The annual household income was ≥$75,000 for 39.5% of the BMT survivors, and 68.4% carried private health insurance. Sixty-two percent of the cohort reported being married. Over 60% (60.7%) of the survivors reported severe/life-threatening chronic health conditions, 16.8% reported depression, 23.1% reported anxiety, and 26.7% reported pain. Table 1: Demographics and Clinical Characteristics of the Study Participants Survivors (N=3 841) Siblings (N=1 261) P-value Suicidal ideation No 3 556 (92.6%) 1 196 (94.8%) 0.0008 Yes 220 (5.7%) 39 (3.1%) Missing answer 65 (1.7%) 26 (2.1%) Age at Study (years) Mean ± SD 53.0 ± 14.6 54.4 ± 14.1 0.002 Median (range) 56.0 (18.0–83.0) 57.7 (18.1–80.9) __ 18–34 566 (14.7%) 165 (13.1%) <.0001 35–49 758 (19.7%) 191 (15.1%) 50–64 1 565 (40.7%) 598 (47.4%) ≥65 952 (24.8%) 307 (24.3%) Sex Female 1 725 (44.9%) 761 (60.3%) <.0001 Race/Ethnicity Non-Hispanic White 2,857 (74.4%) 1 089 (86.4%) <.0001 Hispanic 487 (12.7%) 85 (6.7%) Black 183 (4.8%) 31 (2.5%) Mixed/Other/Unknown 314 (8.2%) 56 (4.4%) Education Level ≤High school 704 (18.3%) 148 (11.7%) <.0001 Some college 1 397 (36.4%) 429 (34.0%) ≥College 1 723 (44.9%) 676 (53.6%) Unknown 17 (0.4%) 8 (0.6%) Income <$50,000 1 274 (33.2%) 258 (20.5%) <.0001 $50000–74999 625 (16.3%) 220 (17.4%) ≥$75000 1 519 (39.5%) 658 (52.2%) Missing 423 (11.0%) 125 (9.9%) Current Insurance Private 2 627 (68.4%) 978 (77.6%) <.0001 Public 1 078 (28.1%) 246 (19.5%) None 113 (2.9%) 37 (2.9%) Missing 23 (0.6%) 0 Marital Status Married 2 379(61.9%) 841(66.7%) <.0001 Single/ Widowed/ Divorced 1 462(38.1%) 414(32.8%) Missing 0 6(0.5%) Chronic Health Condition (severe/ life-threatening) Yes 2 331 (60.7%) 400 (31.7%) <.0001 Depression Yes 645 (16.8%) 102 (8.1%) <0.0001 No 3 159 (82.2%) 1 148 (91.0%) Missing 37 (1.0%) 11 (0.9%) Anxiety Yes 888 (23.1%) 119 (9.4%) <.0001 No 2 934 (76.4%) 1 132(89.8%) Missing 19 (0.5%) 10 (0.8%) Pain Yes 1 024 (26.7%) 197 (15.6%) <0.0001 No 2 781 (72.4%) 1 060 (84.1%) Missing 36 (0.9%) 4 (0.3%) Diagnosis ALL 1 322 (8.4%) NA AML 2 /MDS 3 896 (23.3%) NA CML 4 383 (10.0%) NA HL 5 309 (8.0%) NA NHL 6 940 (24.5%) NA PCD 7 687 (17.9%) NA SAA 8 + Other diagnoses 304 (7.9%) NA Age at BMT <22 569 (14.8%) NA 22–44 1 324 (34.5%) NA 45–64 1 703 (44.3%) NA >65 245 (6.4%) NA Time between BMT and survey completion (years) Median (range) 9.0 (2.0–41.0) NA Year of BMT <1990 315 (8.2%) NA 1990–2004 1 647 (42.9%) NA 2005–2014 1 879 (48.9%) NA Stem cell source Bone Marrow 1 077 (28.0%) NA Cord Blood 201 (5.2%) NA PBSC 2 562 (66.7%) NA Conditioning Intensity MAC 9 2 968 (77.3%) NA NMA 10 / RIC 11 870 (22.7%) NA Missing 3 (0.1%) NA Risk of relapse at BMT High risk 1 710 (44.9%) NA Standard risk 1 669 (43.9%) NA Missing 427 (11.2%) NA Donor Source and Chronic GvHD status Autologous BMT 1 803 (46.9%) NA Allogeneic BMT without cGvHD 910 (23.7%) NA Allogeneic BMT with cGvHD 1 128 (29.4%) NA Total body irradiation No 1 972 (51.3%) NA Yes 1 867 (48.6%) NA Missing 2 (0.1%) NA Open in a new tab 1 ALL = Acute Lymphocytic Leukemia 2 AML = Acute Myeloid Leukemia 3 MDS = Myelodysplastic Syndromes 4 CML = Chronic Myelogenous Leukemia 5 HL = Hodgkin’s Lymphoma 6 NHL = Non-Hodgin’s Lymphoma 7 PDC = Plasma Cell Dyscrasias 8 SAA = Severe Aplastic Anemia 9 MAC = Myeloablative Conditioning 10 NMA = non-Myeloablative Conditioning 11 RIC = Reduced Intensity Conditioning As shown in Table 1 , when compared with BMT survivors, the sibling cohort (n=1 261) was older at survey completion (57.7y vs . 56.0y, p=0.002) and more likely to be female (60.3% vs . 44.9%, p <0.0001), non-Hispanic Whites (86.4% vs . 74.4%, p <0.0001), married (66.7% vs . 61.9%. p <0.0001), and to have a higher annual household income (≥$75,000: 52.2% vs 39.5%, p <0.0001) but less likely to have grades 3–4 chronic health conditions (31.7% vs. 60.7%, p <0.0001). Furthermore, siblings were less likely to report symptoms of depression (8.1% vs 16.8%, p <0.0001), anxiety (9.4% vs 23.1%, p <0.0001) or pain (15.6% vs 26.7%, p <0.0001). Suicidal ideation among BMT survivors vs . siblings Overall, 220 BMT survivors (5.7%) and 39 siblings (3.1%) reported suicidal ideation ( Table 1 ). As shown in Figure 2 and Supplemental Table 2 , univariable analysis revealed a 1.9-fold greater odds of suicidal ideation among BMT survivors compared with the sibling comparison group (95%CI=1.34–2.68, p=0.0003) ( Model 1 ). Multivariable analysis adjusting for sociodemographic characteristics (age at survey completion, sex, race/ethnicity, income, and health insurance), resulted in a decrease in the odds of suicidal ideation among BMT survivors vs . siblings (from odds ratio [OR]=1.90 to OR=1.63, 95%CI=1.1–2.3, p=0.007) ( Model 2 ). Addition of marital status to the sociodemographic characteristics ( Model 3 ) did not change the odds of suicidal ideation among BMT survivors vs. siblings (OR=1.61, 95%CI=1.1–2.3, p=0.009). However, addition of pain to sociodemographics ( Model 4 ) resulted in a decrease in odds (OR=1.44, 95%CI=1.0–2.2, p=0.048), although the survivors remained at a statistically significantly elevated odds of suicidal ideation when compared to the non-BMT comparison group. Substituting pain with chronic health conditions ( Model 5 ) resulted in a further decline in the odds of suicidal ideation among BMT survivors vs. non-BMT controls (OR=1.37, 95%CI=0.95–1.98, p=0.09). Addition of depression to sociodemographics ( Model 6 ), resulted in a substantial reduction in the odds of suicidal ideation among BMT survivors vs. siblings (OR=1.20, 95%CI=0.8–1.8, p=0.34) as did addition of anxiety to sociodemographics ( Model 7 : OR=1.14, 95%CI=0.8–1.7, p=0.48). Finally, inclusion of all the above variables resulted in abrogation of any increase in odds of suicidal ideation among BMT survivors vs. non-BMT controls ( Model 8 : OR=0.97, 95%CI=0.7–1.4, p=0.87). Figure 2: Odds of Suicidal Ideation in Survivors vs Siblings. Open in a new tab Model 1: bivariate associations with suicidal ideation Model 2: sociodemographics (age, sex, race/ethnicity, income, insurance) Model 3: sociodemographics (age, sex, race/ethnicity, income, insurance) + marital status Model 4: sociodemographics (age, sex, race/ethnicity, income, insurance) + pain Model 5: sociodemographics (age, sex, race/ethnicity, income, insurance) + chronic health conditions Model 6: sociodemographics (age, sex, race/ethnicity, income, insurance) + depression Model 7: sociodemographics (age, sex, race/ethnicity, income, insurance) + anxiety Model 8: all above variables Predictors of suicidal ideation among BMT survivors Multivariable analysis revealed the following to be significantly associated with suicidal ideation among BMT survivors: male sex (OR=1.38, 95%CI=1.02–1.87), being divorced (OR=1.74, 95%CI=1.13–2.67; reference: married), and reporting anxiety (OR=2.32, 95%CI=1.66–3.26) ( Table 2 ). Given a statistically significant interaction between depression and pain (p <0.01), we created a composite variable and found the highest odds of suicidal ideation among those with both pain and depression (OR=10.67, 95%CI=6.71–16.97; reference: no depression or pain). Of note, suicidal ideation was not associated with age at study, race/ethnicity, or severe/life-threatening chronic health conditions ( Table 2 ). Table 2. Predictors of Suicidal Ideation among BMT Survivors Univariate Analysis Multivariate Analysis OR (95% CI) p-value OR (95% CI) p-value Age at Study (reference: ≥65 years) 18–34 2.99 (1.93–4.64) <.0001 1.56 (0.93–2.64) 0.10 35–49 1.95 (1.25–3.04) 0.003 0.95 (0.58–1.55) 0.83 50–64 1.41 (0.93–2.12) 0.10 0.87 (0.56–1.36) 0.55 Sex (reference: females) Males 1.04 (0.79–1.37) 0.78 1.38 (1.02–1.87) 0.04 Race/Ethnicity (reference: non-Hispanic White) Black 0.78 (0.38–1.62) 0.51 - - Hispanic 1.32 (0.90–1.94) 0.15 - - Other 1.10 (0.67–1.79) 0.71 - - Income (reference: >$75000) <$75,000 2.15 (1.56–2.96) <.0001 - - Insurance (reference: private) Public 0.42 (0.22–0.78) 0.006 - - None 0.72 (0.38–1.37) 0.32 - - Marital Status Married Ref Ref Never Married 2.00 (1.42–2.82) <.0001 1.40 (0.93–2.10) 0.10 Separated 2.87 (1.20–6.88) 0.0181 2.50 (0.96–6.52) 0.06 Divorced 1.92 (1.31–2.82) 0.0009 1.74 (1.13–2.67) 0.01 Widowed 0.38 (0.09–1.55) 0.1757 0.47 (0.11–2.02) 0.31 Other 1.50 (0.46–4.93) 0.4998 1.31 (0.37–4.67) 0.67 Grades 3–4 chronic health conditions (reference: no grade 3–4 chronic health conditions) Yes 1.37 (1.03–1.83) 0.033 - - Depression (reference: no) Yes 12.12 (9.03–16.28) <.0001 - - Anxiety (reference: no) Yes 5.90 (4.45–7.83) <.0001 2.32 (1.66–3.26) <.0001 Depression plus Pain ( reference: both no) No depression; yes pain 2.50 (1.56–4.01) <.0001 2.34 (1.44–3.79) 0.0006 Yes depression; no pain 15.56 (10.45–23.17) <.0001 10.14 (6.57–15.62) <.0001 Yes depression; yes pain 17.56 (11.66–26.43) <.0001 10.67 (6.71–16.97) <.0001 Relapse(reference: no) Yes 0.56 (0.31–1.02) 0.0585 0.53 (0.28–1.00) 0.0493 Pain (reference: no) Yes 2.44 (1.84–3.22) <.0001 - - Primary Cancer Diagnosis (reference: ALL) ALL 1 0.80 (0.49–1.32) 0.39 - - AML 2 /MDS 3 0.68 (0.37–1.25) 0.21 - - CML 4 0.80 (0.43–1.49) 0.48 - - HL 5 0.64 (0.39–1.07) 0.09 - - NHL 6 0.57 (0.33–0.99) 0.045 - - PCD 7 1.11 (0.62–2.00) 0.72 - - Stem cell type (reference: bone marrow) Cord Blood 1.06 (0.60–1.88) 0.85 - - PBSC 9 0.68(0.51–0.91) 0.009 - - Donor source and cGvHD (reference: autologous BMT) Allogeneic BMT without cGvHD 1.13 (0.80–1.59) 0.50 - - Allogeneic BMT with cGvHD 1.25 (0.91–1.71) 0.17 - - Total body irradiation (reference: no TBI) Yes 1.10 (0.84–1.44) 0.50 - - Conditioning Intensity (reference: MAC 10 ) NMA 11 / RIC 12 0.89 (0.64–1.25) 0.51 - - Site of BMT (reference: UMN) City of Hope 0.93 (0.69–1.25) 0.62 - - University of Alabama at Birmingham 0.90 (0.51–1.58) 0.71 - - Open in a new tab 1 ALL = Acute Lymphocytic Leukemia 2 AML = Acute Myeloid Leukemia 3 MDS = Myelodysplastic Syndromes 4 CML = Chronic Myelogenous Leukemia 5 HL = Hodgkin’s Lymphoma 6 NHL = Non-Hodgin’s Lymphoma 7 PDC = Plasma Cell Dyscrasias 8 SAA = Severe Aplastic Anemia 9 PBSC = Peripheral Blood Stem Cells 10 MAC = Myeloablative Conditioning 11 NMA = non-Myeloablative Conditioning 12 RIC = Reduced Intensity Conditioning Antidepressant use in BMT survivors Given the strong association between depression and anxiety and suicidal ideation, the use of antidepressants in survivors was explored. Patients were asked “ Have you ever taken medications for depression such as Adapin, Anafranil, Aventyl, Celexa, Cymbalta, Desyrel (trazodone), Effexor, Elavil, Lexapro, Ludiomil, Luvox, Marplan, Nardil, Norpramin, Pamelor, Parnate, Paxil, Pertofrane, Prozac, Serzone, Sinequan, Surmontil, Tofranil, Remeron, Vivactil, Wellbutrin, Zoloft, or others ?” While survivors endorsing suicidal ideation were significantly more likely to report use of antidepressants (55.5% vs. 27.5%, p <0.0001) ( Table 3 ), a substantial proportion of the survivors (n=89; 40.5%) experiencing suicidal ideation reported never having used antidepressants. Furthermore, among the 89 BMT survivors with suicidal ideation who had not received antidepressants, 56.2% (n=50) reported symptoms suggestive of depression and 50.6% (n=45) reported symptoms suggestive of anxiety. Table 3: Antidepressant use by suicidal ideation among BMT survivors No suicidal ideation (N = 3 556) Suicidal Ideation (N = 220) Missing (N = 65) p-value Have Ever Taken Antidepressant Medication 979 (27.5%) 122 (55.5%) 18 (27.7%) <0.0001 Have Not Ever Taken Antidepressants 2 502 (70.4%) 89 (40.5%) 27 (41.5%) Unsure 75 (2.1%) 9 (4.1 %) 20 (30.8%) Open in a new tab DISCUSSION In the current report, we observed that the odds of suicidal ideation were nearly twice as high among BMT survivors when compared to a non-transplant comparison group. Differences in annual household income, severe/life-threatening chronic health conditions, pain, depression, and anxiety explained the higher odds of suicidal ideation among BMT survivors vs . the non-transplant comparison group. Among BMT survivors, lower annual household income, being divorced, experiencing pain, depression, or anxiety were associated with suicidal ideation. We found that BMT survivors with suicidal ideation were more likely to have used antidepressants when compared with those without suicidal ideation; however, 40% of the survivors with suicidal ideation reported never using antidepressants. Suicidal ideation has been reported in childhood cancer patients in the early post-treatment phase 13 , 14 as well as by long-term survivors of childhood cancer 6 , 15 , where the prevalence is reported to be significantly greater than in a sibling comparison group. Breast cancer and gynecologic cancer survivors are significantly more likely to die by suicide then their general population counterparts. 16 , 17 Prostate cancer survivors are more likely to report having ‘serious thoughts of committing suicide’ with suicidal ideation found to closely relate with physical health. 18 Tichelli et al leveraged the European BMT Registry to examine the rates of completed suicides among individuals treated with BMT between 1980 and 2009, and found a two-fold greater risk of death from suicides among BMT recipients as compared with the European general population; however they were unable to examine suicidal ideation. 10 Our cohort included BMT survivors who were a median of 9y from BMT and had received transplants across the age spectrum. We found that 6% of the survivors experienced suicidal ideation – a rate that was nearly two times that observed in the non-transplant comparison group. Furthermore, the excess risk of suicidal ideation among BMT survivors relative to the siblings was explained by differences in annual household income, and the prevalence of pain, depression, anxiety, and severe/life-threatening chronic health conditions between the two groups. We observed that the BMT survivors with suicidal ideation were more likely to be divorced, and more likely to experience pain and suffer from depression or anxiety. While the rates of marriage in childhood cancer survivors and rates of consequential divorce or separation in adult cancer survivors have been explored, the way that psychological factors interplay with marriage or lack thereof remains unclear. 19 – 22 Nonetheless, being married is not only associated with superior survival in cancer patients but is also a protective factor against suicidal ideation. 23 – 25 Although being married may contribute to financial security, our data demonstrate an inverse association between marital status and suicidal ideation, independent of the annual household income, suggesting that being married perhaps contributes toward social support, mitigating the risk of anxiety and depression. The association between anxiety and suicidal ideation in BMT survivors builds on the relationship of anxiety as an independent predictor of suicidal ideation in non-cancer populations, highlighting the complex psychology that underlies suicidal ideation. 26 – 28 Unsurprisingly, the greater odds of suicidal ideation among BMT survivors reporting symptoms of depression in our study has been reported in other cancer populations as well. 7 , 15 , 29 , 30 Depression was associated with a 12-fold greater risk of suicidal ideation in childhood cancer survivors. 30 Nonetheless, it is concerning that among the BMT survivors who reported suicidal ideation, 40% had never received antidepressants, suggesting a need to screen for depression and provide appropriate management. 31 Mental health conditions are at the crossroads of a unique double jeopardy: battling the stigma and discrimination of a mental health condition can be as or more difficult than managing the mental health condition itself. 32 Combined with affordability being the greatest barrier in access to care wherein those experiencing mental health challenges face more barriers overall, it is no surprise that such a profound gap in mental health need and coverage exists. 33 When looking at cancer survivors and more specifically BMT survivors, the financial hardship associated with cancer care and the stigma against cancer unquestionably mix with the culture and climate around mental health in the US to suggest a landscape of cancer survivorship permeated by a profound gap in survivor mental health and well-being thus leaving space for suicidal ideation to take root. Survivors experiencing pain were more likely to report suicidal ideation than those without pain. Pain (particularly chronic pain), is prevalent among conventionally-treated cancer patients as well as BMT survivors. 34 , 35 BMT survivors were found to be at 2.6-fold odds of reporting chronic severe pain compared to a sibling cohort. 36 Unfortunately, cancer survivors may not receive adequate pain control thus leading to a lifetime of chronic pain. 37 Persistent pain can lead to lower quality of life often compounded by depression and suicidal ideation. 38 As such, while pain and depression are inextricably linked, our findings show the unique but equally important impact of depression and pain as informants of suicidal ideation in BMT survivors. These gaps are also notable and hopeful areas for intervention. Though screening guidelines exist surrounding depression and anxiety with recent changes focusing on a stepped approach to screening, it is possible that periodic universal screening could be warranted to ensure complete capture and log trends in mental health. 39 Antidepressants are widely available and have the potential to reduce suicidal ideation offering a vital therapeutic option for addressing suicidal ideation while concurrent psychotherapy efforts continue to evolve in efficacy and accessibility. 40 Overall, these data inform the need for system-level changes in long-term follow-up of BMT survivors with increased attention to mental health. This study needs to be considered in the context of its limitations. First, our cohort included patients transplanted between 1974 and 2014, and, while the prevalence of suicidal ideation did not differ across the four decades ( data not shown ), we do acknowledge that we do not capture the more contemporary era with the changes in transplant strategies. Second, cohort entry required survival of two or more years after BMT, possibly introducing the risk of survival bias and an underestimation of the suicidal ideation rates. Third, our cohort did not collect data on gender or sexual orientation. Fourth, the vast majority of our patients underwent transplants for hematologic malignancies. Specifically, the cohort did not have sufficient number of patients with sickle cell disease and hence we could not examine suicidal ideation in vulnerable subpopulations. Fifth, this study did not capture suicidal ideation or depression prior to transplant, or details about past suicidal attempts or other self-injuring behaviors. Sixth, we used a single item from the BSI (similar to prior studies in cancer survivor populations 6 ) and did not conduct a detailed suicide ideation evaluation 41 , 42 . Seventh, while our study concludes that depression and anxiety are strong predictors of suicidal ideation among cancer survivors, we assessed these solely through self-report, and thus, our results are subject to recall and acceptability bias. Eighth, when investigating the relationship of antidepressants to suicidal ideation, it would be anticipated that antidepressants were prescribed for major depressive disorder. That said, there are a multitude of uses and reasons why a patient may or may not be prescribed an antidepressant beyond major depressive disorder like anxiety, chronic pain, hot flashes, etc. Furthermore, our survey did not query the use of psychotherapy for management of depression. These limitations notwithstanding, we report the risk of suicidal ideation in BMT survivors followed several years after BMT. We identify factors that are associated with suicidal ideation, which when addressed could significantly reduce the risk in this vulnerable population. Supplementary Material 1 NIHMS2180454-supplement-1.docx (25.8KB, docx) Highlights. BMT survivors were twice as likely to experience suicidal ideation when compared with a non-transplant comparison group. This difference was explained by the higher prevalence of pain, depression, anxiety, and severe/life-threatening chronic health conditions among BMT survivors. BMT survivors who were divorced, those with symptoms suggestive of depression and anxiety, and those reporting pain were more likely to experience suicidal ideation. Key points. BMT survivors were twice as likely to experience suicidal ideation when compared with a non-transplant comparison group. This difference was explained by the higher prevalence of pain, depression, anxiety, and severe/life-threatening chronic health conditions among BMT survivors. BMT survivors who were divorced, those with symptoms suggestive of depression and anxiety, and those reporting pain were more likely to experience suicidal ideation. Acknowledgements: This work was supported in part by the National Cancer Institute (R01 CA078938; U01 CA213140; S Bhatia), and the Leukemia and Lymphoma Society (R6502-16; S Bhatia). Footnotes Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. 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Am J Psychiatry 164:1035–43, 2007 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Associated Data This section collects any data citations, data availability statements, or supplementary materials included in this article. Supplementary Materials 1 NIHMS2180454-supplement-1.docx (25.8KB, docx) Data Availability Statement The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request. ACTIONS View on publisher site PDF (547.9 KB) Cite Collections Permalink RESOURCES Similar articles Cited by other articles Links to NCBI Databases Follow NCBI NCBI on X (formerly known as Twitter) NCBI on Facebook NCBI on LinkedIn NCBI on GitHub NCBI RSS feed Connect with NLM NLM on X (formerly known as Twitter) NLM on Facebook NLM on YouTube National Library of Medicine 8600 Rockville Pike Bethesda, MD 20894 Web Policies FOIA HHS Vulnerability Disclosure Help Accessibility Careers NLM NIH HHS USA.gov Back to Top

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