Predictors of Suicidal Ideation in Chronic Pain Patients

This blog post relates to an article entitled Predictors of Suicidal Ideation in Chronic Pain Patients: An Exploratory Study that Dr. Manon Choinière, Dr. Warren Nielson and I have recently published in The Clinical Journal of Pain [4].  (To read this same blog post in French please click here).

Suicide has always been a very sensitive topic to touch upon, whether it be about “suicidal ideations” (SI), “suicide attempts” (SA) or — god forbid — suicide completion. According to the World Health Organization, death by suicide is one of the leading causes of mortality rate every year (16 per 100, 000 individuals) [6]. The worldwide lifetime prevalence for passive (without plan) and active (with a plan) SI, and SA have been estimated to be 9.2%, 3.1% and 2.7% respectively [3]. In many cases, there is a progression from passive suicidal thoughts to more active thoughts, which may be followed by SAs and in some unfortunate cases, death.

Suffering from chronic pain (CP) seems to be an important at-risk factor for suicidality. A recent literature review has demonstrated that in comparison to the general population, individuals with CP where 2 to 3 times more likely to exhibit SI, SA and to complete suicide [5]. The primary objective of our study was to examine whether CP patients with or without current suicidal thoughts present a distinctive profile in terms of their sociodemographic characteristics, physical health, mental well-being, cognitions, antidepressant intake, and their use of illicit drugs and alcohol for pain relief. The secondary objective was to assess the frequency of passive and active SI and previous SA within the last 12 months and since the onset of CP.

Eighty-eight CP patients have been recruited before their first intake assessment at 1 of 3 large university-affiliated multidisciplinary pain clinics located in the province of Quebec, Canada. Patients who accepted to participate in the study were asked to complete a self-administered battery of questionnaires. Our results showed that one quarter of CP patients reported either passive (20%) or currently active (5%) SI. When patients were further questioned about suicidality within the last year, we obtained results showing that 28% had seriously considered suicide, 11% had a concrete plan and 2% had previously made a SA. The proportion was even higher when we inquired about suicidality since the onset of their CP. In comparison, less than 4% of the general Canadian population has reported SI, and it is estimated that less than 1% has reported previous SAs [1; 2].

CP patients that were reporting current active or passive SI where compared to those reporting no SI on 26 independent variables. The statistically significant variables where then entered into 5 different regression analyses in order to identify the factors that could significantly and independently predict current SI. Results showed that patients that were unemployed/disabled were 6 times more likely to report SI. One explanation might be that these patients succumb to negative cognitions such as guilt and helplessness due to their perceived uselessness and diminution of social role (e.g. purveyor). Another plausible explanation may be that patients reporting SI had more difficulty in coping with their pain, making it harder for them to convince themselves of returning to work. In line with previous literature, we also found that poor sleep quality was the only predictor of SI among the physical variables tested. We have also obtained a surprising result, namely that depressive symptoms did not significantly predict SI when mental health was taken into account — i.e. the poorer the patients perceived their mental health to be, the more likely they were to report SI. Interestingly, our results are in line with the ones found in the Quebec’s general population where SI prevalence was only 3% in individuals who judged their mental health to be good, very good or excellent, 15% in those who thought it was average, and 43% in those who perceived it to be poor [1]. With regards to cognitive factors we found that the more pain-related helplessness patients felt, the more likely they were to report suicidal ideation. Our results also showed that patients who reported using or having used illicit drugs as a form of pain relief at any time since their pain onset were 5 times more likely to report SI. Again these results may suggest poorer coping strategies by patients presenting SI compared to those who don’t. Finally, patients who were taking prescribed antidepressants were 5 times more prone to reporting SI, suggesting that physicians might be more inclined to prescribe antidepressants to patients who reported more severe depressive symptoms and SI.

In summary, better identification and understanding of the risk factors associated with SI in people with CP is essential for the development of tools for early identification of SI and targeted suicide prevention programs aimed at high-risk CP patients.

About Mélanie Racine

grey Predictors of Suicidal Ideation in Chronic Pain PatientsDr Mélanie Racine completed her graduate studies at the department of psychology of the Université du Québec à Montréal, Quebec, Canada. Her thesis aimed to better understand the biospychosocial profile of sex and gender differences in experimental and chronic pain perception. She is also a skilled cognitive-behavioral psychologist with an extensive clinical training in health psychology and chronic pain management. Dr. Racine is pursuing her postdoctoral fellowship at the Lawson Research Health Institute and at St. Joseph’s Health Care, London, Ontario, Canada with Dr. Warren Nielson (supervisor) and Dr. Mark P. Jensen (co-supervisor), University of Washington, Seattle, USA. Her current research focuses on examining the effectiveness of two different kinds of activity pacing interventions in fibromyalgia syndrome. She is also actively involved in other research projects including the development of an activity management index for chronic pain individuals, the investigation of sex and gender differences as well as suicidal ideation in Fibromyalgia sufferers, the examination of the predicting factors of quality of life and disability in neuropathic pain patients, as well as the clinical correlates of pain versus itching within sufferers of scleroderma.

References

[1] Daveluy C, Pica L, Audet N, Courtemanche R, Lapointe F. Enquête sociale et de santé 1998. Book Enquête sociale et de santé 1998. City, 2000.

[2] Government of Canada. The Human Face of Mental Health and Mental Illness in Canada 2006. Book The Human Face of Mental Health and Mental Illness in Canada 2006. City, 2006.

[3] Nock MK, Borges G, Bromet EJ, Alonso J, Angermeyer M, Beautrais A, Bruffaerts R, Chiu WT, de Girolamo G, Gluzman S, de Graaf R, Gureje O, Haro JM, Huang Y, Karam E, Kessler RC, Lepine JP, Levinson D, Medina-Mora ME, Ono Y, Posada-Villa J, & Williams D (2008). Cross-national prevalence and risk factors for suicidal ideation, plans and attempts. British Journal of Psychiatry, 192 (2), 98-105 PMID: 18245022

[4] Racine M, Choinière M, & Nielson WR (2013). Predictors of Suicidal Ideation in Chronic Pain Patients: An Exploratory Study. Clinical Journal of Pain PMID: 23887336

[5] Tang NK, & Crane C (2006). Suicidality in chronic pain: a review of the prevalence, risk factors and psychological links. Psychological Medicine, 36 (5), 575-86 PMID: 16420727

[6] WorldHealthOrganization. Mental health : Sucide prevention (SUPRE). Book Mental health : Sucide prevention (SUPRE), Vol. 2012. City: World Health Organization, 2011.

Comments

  1. stuart miller says:

    Dr. Racine, thanks for your important work. I was wondering if screening tools such as PHQ9 (or even PHQ2) have potential risks if used outside of settings (multidisciplinary or otherwise) with timely psychological support? If tools are used that screen for SI but then there is not timely support (other than referring back to family doctor or phone numbers for distress centres) is it possible that it may take someone with passive SI and increase focus on symptoms (active SI) ? Do you have any suggestions for therapists in community settings on appropriate screening tools ? Thanks.