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SAN DIEGO -- Whether it's due to the side effects of local and systemic therapies, or the diagnosis itself, men with prostate cancer are at increased risk of mental distress and suicide.

The mental health burden associated with a diagnosis and treatment is substantial, pointed out Zachary Klaassen, MD, of the Georgia Cancer Center at Augusta University, during a session of the annual meeting of the Society of Urologic Oncology.

For example, Klaassen referred to a of about 50,000 older men with prostate cancer, which found that 20% developed a mental health illness over a follow-up period of 55 months.

Furthermore, he noted, studies have indicated that administration of systemic therapy, such as androgen deprivation therapy (ADT), can severely impact the mental health of patients with both localized and advanced disease. A study in found that of more than 37,000 men with prostate cancer treated with ADT, 11% received a new diagnosis of depression or anxiety at a median time of 9.3 months from the initiation of ADT.

"Only 50% of these men received treatment for their depression or anxiety," said Klaassen.

As for the question of suicide risk, a study Klaassen co-authored in uncovered 2,268 suicides among 1.2 million individuals with genitourinary cancers from 1988 to 2010. Risk factors included Caucasian race, male sex, older age, and distant disease.

"What is particularly interesting is that if we tease out the prostate cancer data, even at 15 years after diagnosis the standardized mortality ratio was 1.84 compared to the general population," Klaassen said. "This really lends to the fact that these men are going to be high-risk even years and years after their diagnosis."

So, how can oncologists help reduce these risks among their patients with prostate cancer?

"This is not easy to talk about -- there are some definite barriers to identifying suicidality," Klaassen said.

He cited a that found that a majority of oncologists and nurses managing cancer patients reported at least one patient who experienced suicidal ideation or had died by suicide during their career.

The 61 oncology healthcare professionals interviewed said there were a number of barriers to identifying suicide risk, including:

• Difficulty differentiating between suicidality and mental health distress
• Patients gave no warning or concealed suicidality
• A fear of asking about suicidality
• A lack of coping resources and training to deal with suicidal patients

"One of the main ones that I see in our clinics is our lack of time," said Klaassen. "The take home from this study for identifying suicidal risk is being attentive to verbal indicators, looking for explicit actions in our patients, paying attention to their previous history of mental health disorders ... and really being attentive to acute mental health."

One way of doing that, he said, is with the , a 0-10 scale (none to extreme) in which patients indicate their level of distress over the course of of the week prior to assessment.

Be on the lookout for depression, mental illness, and suicide ideation in patients, said Klaassen. "It should be easy to do that with the mental stress thermometer and by training your staff to understand what that is, administer it, and bring it to your attention if they see a signal of a score of 3 or higher."

"We're all prostate cancer doctors here," he said. "Your job is to treat prostate cancer the best you can, but make the referrals to your urology colleagues that deal with sexual matters and urinary incontinence, because it is in that localized state that they are going to have their issues. And make friends with your psycho-oncology team at the same time."

Klaassen noted that he works closely with a multidisciplinary team that includes a psycho-oncologist and a sexual medicine oncologist "who are very important in this prostate cancer journey."

"At that time between biopsy and treatment, we offer [patients] a visit with both of these physicians to discuss the side effects of the treatment and mental stress, and then we again give them that opportunity after their primary treatment," Klaassen said. "Don't be afraid to make the appropriate referrals, and sometimes they may be urgent, to the psycho-oncology or psychiatric teams."

If you or someone you know is having thoughts of suicide, please call the 988 Suicide & Crisis Lifeline.

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