The Impact of Physical Pain on Suicidal Thoughts and Behaviors

Clinical Pain Advisor 

November 19, 2015
Michael O’Leary

Chronic pain affects 100 million Americans and costs the nation up to $635 billion each year in medical treatments and lost productivity, according to a 2011 report by the Institute of Medicine examining chronic pain as a public health problem.1

The depth of the problem was brought into sharp focus last month with a report from Princeton researchers2 showing a unique and startling rise in midlife mortality among white, non-Hispanic Americans driven, in part, by suicides and drug poisonings. (published site) 

Just how many of those people are driven to suicide by pain remains unclear — without a note or other evidence, intentional opioid overdose cannot be differentiated from accidental overuse.

Although numerous studies have established a positive association between pain and suicide, the number of different physical pain types, spectrum of suicidal behaviors studied, and variety of study designs make it difficult to know which patients are at greatest risk, Raffaella Calati, PhD, from the University of Montpellier, in Montpellier, France, told Clinical Pain Advisor.

Collaborating with researchers in Morocco and the United States, Dr. Calati and colleagues conducted a meta-analysis to provide a comprehensive overview of the phenomenon, and evaluate the extent to which suicidal thoughts and behaviors differ among individuals with and without physical pain. The analysis appears in the December 2015 Journal of Psychiatric Research.3

Pain Doubles Suicidality Risk

The meta-analysis included 31 studies of suicidality in patients with any type of pain, including headache, back, neck, chest, musculoskeletal, abdominal, and pelvic pain, as well as arthritis, fibromyalgia, and other pain-related conditions.

Three of the studies analyzed lifetime death wish, 11 published studies (and 1 unpublished study) focused on current suicide ideation, 6 reported on patients who engaged in current suicide planning, 9 looked at current suicide attempts, and 8 studied suicide deaths. Some studies looked at more than one suicidal behavior.

Results showed that individuals with physical pain were more likely than those without to show suicidal behavior across the spectrum of suicidality. The risk for lifetime death wish increased by half (odds ratio [OR] = 1.50; 95% confidence interval [CI], 1.19 - 1.88; P = .0005), and risks for current and lifetime suicidal ideation were more than doubled (OR = 2.11 [95% CI, 1.64 - 2.71] and OR = 2.01 [95% CI, 1.91 - 2.12]; P < .00001 for both comparisons).

Physical pain also more than doubled the risks for suicide planning (OR = 2.60; 95% CI, 1.49 - 4.54; P = .0008), current suicide attempts (OR = 2.54; 95% CI, 1.66 - 3.89; P < .00001), and lifetime suicide attempts (OR = 2.15; 95% CI, 1.73 - 2.68; P < .00001). Patients with physical pain were also more likely to die from suicide (OR = 1.34; 95% CI, 1.05 - 1.71; P = .02).

Although the findings confirm what is known, coalescing the data into a single analysis provides clinicians and researchers a quick reference summary, according to Jennifer Brennan Braden, MD, psychiatrist and affiliate assistant professor at the University of Washington, Seattle. Dr. Braden specializes in pain and was lead author of a study included in the meta-analysis.

“What is nice about this paper is that they have brought all these different research studies together and given an odds ratio for different aspects of suicidality along the continuum,” Dr. Braden told Clinical Pain Advisor. "I think it is nice to be able to look at that, and in particular to see that there is an increased risk for each of those areas along the continuum.”

The authors cite the heterogeneity of the studies as a limitation of their analysis, and suggest that future research focus more on specific pain types and the contributions of neural systems of physical and social/psychological pain.

“Further research should more closely focus on specific risk factors for suicide in chronic pain patients. For example, type, severity and duration of pain; access to analgesics; helplessness and hopelessness about pain,” Dr. Calati said. “Concerning pain type, the relationship between specific pain conditions (medically unexplained pain) and suicide should be better dissected.”

Screening Recommended

According to Dr. Calati, the analysis underscores the importance of screening pain patients for suicidality.

“The main take-away message of our paper is that clinicians treating patients with pain should be aware of the increased suicide risk, and always carefully monitor suicidal thoughts and plans and lifetime suicide attempts in these patients,” Dr. Calati said, noting that doing so may help diminish suicidal risk.

Dr. Braden concurs, but points out that other factors may also play a role in suicide.

“One thing we do know about suicide in general is that over 90% of suicide victims have a diagnosable psychiatric illness, most commonly a mood disorder. Hence, providers need to routinely screen for and treat depression in these patients,” Dr. Braden concluded.

References

1. Institute of Medicine (US) Committee on Advancing Pain Research, Care, and Education. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education and Research. Washington (DC): National Academies Press (US); 2011.

2. Case A, Deaton A. Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century. PNAS. 2015; published ahead of print November 2, 2015. doi:10.1073/pnas.1518393112

3. Calati R, Laglaoui Bakhiyi C, Artero S, Ilgen M, Courtet P. The impact of physical pain on suicidal thoughts and behaviors: Meta-analyses. J Psychiatr Res. 2015 Dec;71:16-32. doi:10.1016/j.jpsychires.2015.09.004. Epub 2015 Sep 11. Review.