Suicide risk in patients with chronic pain and depression

Assessing suicide risk in patients with chronic pain and depression : Current Pain Perspectives

Evidence links pain with suicidal thoughts

…studies show that people …. who experience chronic pain are more likely to develop depression than those without pain, and suicidal ideation is highly comorbid with chronic pain

Risk factors for suicidal ideation include

  • being unemployed or disabled,
  • poor sleep quality,
  • self-perceived mental health status,
  • pain-related sense of helplessness, and
  • a history of using illicit drugs,

according to a survey by Racine et al. Among 88 patients the researchers surveyed at several pain clinics, 24% reported active or passive suicidal ideation. Similarly, a survey of 153 individuals with chronic noncancer pain found passive suicidal ideation in 19%, active ideation in 13%, a plan for suicide in 5%, and a past suicide attempt in 5%. Drug overdose was the most commonly reported method for attempting suicide.10

Pain-specific risk factors include location (low back and widespread pain), intensity (high), duration, and concomitant insomnia.

Catastrophizing and feelings of being a burden also are associated with suicidal ideation in the pain population. Studies of patients with complex regional pain syndrome (CRPS) or fibromyalgia have shown particularly high rates of suicidal ideation (74% and 48%, respectively)

Interpersonal theory of suicidal ideation

How does a person with chronic pain develop suicidal ideation? A prevailing model, called the interpersonal theory of suicide, proposes that suicidal thoughts or desire arise from the confluence of 2 factors:

  1. thwarted belongingness (unfulfilled need for social interaction or connectedness) and
  2. perceived burdensomeness (perceiving oneself as a burden or liability to others).

Suicidal desire progresses to lethal action when an individual habituates to the fear of the potential pain of self-harm. Over time, they may become numb to their emotional and physical pain, which increases the risk of suicide.

Opioid use is another contributing factor, as the rate of “unintentional” opioid-related fatalities is related to the dosage of prescribed opioids. A notable number of these overdoses most likely are suicides.

When studies ascribe harms to opioid use, they are pointing not to the cause of the harm, but to a result of the initial cause, which is chronic pain.  Most harms linked to opioids are actually harms arising from having chronic pain, but the current media-promoted trend is to blame the medication which people take for their pain, not the pain itself.

Based on this model, the risk of suicide is high in a person who

  1. perceives no purpose in life,
  2. becomes isolated from family and friends, and
  3. is on a high-dose opioid or is abusing opioids. (which implies serious chronic pain)

Suicide risk factors and screening

In the chronic pain population, risk factors for suicide may be general or pain-specific (TABLE 1). Individuals with the following risk factors may be particularly vulnerable to suicide:

  • inability to return to gainful employment
  • isolation and feelings of burdensomeness
  • loss of important family and social roles
  • recent or current substance use disorder
  • depression.


Proactive care and intervention

To reduce the risk of suicidal ideation, target potential mediators of pain and suicide such as inadequate pain control, poor pain coping skills, and sleep disorders.

Routine care strategies

encourage patients to structure out-of-house time and to be productive in some manner, such as volunteering in the community.

co-treat these complex patients with a team consisting of psychiatrists, psychologists or other mental health clinicians, and pain physicians

If a patient begins to display signs of distress

Maintain an open, nonjudgmental dialogue with the patient in discussing the risk of suicide and the importance of adhering to treatment.

prescribe the opioids in small amounts with family members dispensing the medications

Perform frequent urine drug screenings to ensure that they are using their opioids appropriately and not hoarding them for a suicide attempt.

Low or high risk of suicide?

based on various factors, including:

  • specific plans for suicide
  • means (access to guns, lethal supply of medications)
  • history of suicide attempts
  • level of social support
  • effectiveness of coping skills
  • relationship with the health care provider (does the patient communicate emotional status and life stressors?)
  • willingness to contract for safety (a written compact stating that if they become seriously suicidal with plans and intent, they will call 911, go the local emergency department, and contact your office).

If a patient admits to an acute suicidal ideation, is unwilling to contract, and has a plan for suicide, inpatient admission is warranted.

The stress of the holidays and dark, cold winter days (in the Northern Hemisphere, at least) make this time of year challenging for those of us with pain and depression. I take comfort in one of the few happy certainties of life: spring will come again!


For any patient who feels their pain and depression aren’t being taken seriously, you can show this article to your healthcare provider, along with its eight most pertinent sources (since 2004) as further scientific evidence.

Original article link:

Scientific Studies:

Smith MT, Edwards RR, Robinson RC, et al. Suicidal ideation, plans, and attempts in chronic pain patients: factors associated with increased risk. Pain. 2004;111:201-208.

Braden JB, Sullivan MD. Suicidal thoughts and behavior among adults with self-reported pain conditions in the National Comorbidity Survey Replication. J Pain. 2008;9:1106-1115

Ilgen MA, Zivin K, McCammon RJ, et al. Pain and suicidal thoughts, plans and attempts in the United States. Gen Hosp Psychiatry. 2008;30:521-527.

Ratcliffe GE, Enns MW, Belik SL, et al. Chronic pain conditions and suicidal ideation and suicide attempts: an epidemiologic perspective. Clin J Pain. 2008;24:204-210.

Tang NK, Crane C. Suicidality in chronic pain: a review of the prevalence, risk factors and psychological links. Psychol Med. 2006;36:575-586.

Cheatle M, Wasser T, Foster C, et al. Prevalence of suicidal ideation in patients with chronic noncancer pain referred to a behaviorally based pain program. Pain Phys. In press

Bohnert AS, Valenstein M, Bair MJ, et al. Association between opioid prescribing patterns and opioid overdose-related deaths. JAMA. 2011;305:1315-1321.

Cheatle MD. Depression, chronic pain, and suicide by overdose: on the edge. Pain Med. 2011;12(suppl 2):S43-S48.


One thought on “Suicide risk in patients with chronic pain and depression

  1. painkills2

    “co-treat these complex patients with a team consisting of psychiatrists, psychologists or other mental health clinicians, and pain physicians”

    The team approach to treating chronic pain is a good one, but it is a damn expensive one. Who can afford one doctor, let alone a team? And for how long? The medical industry has been advocating for the team approach for years, but the insurance companies keep saying “no.”

    And here’s what the medical industry doesn’t understand when it comes to chronic pain and suicide: What else can doctors offer in the way of treatments for a pain patient who can’t take the pain anymore? Detox? Massage therapy?



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