Other 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.
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,22,23 proposes that suicidal thoughts or desire arise from the confluence of 2 factors:
- thwarted belongingness (unfulfilled need for social interaction or connectedness) and
- 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.24 A notable number of these overdoses most likely are suicides.
Based on this model, the risk of suicide is high in a person who perceives no purpose in life, becomes isolated from family and friends, and is on a high-dose opioid or is abusing opioids.
Suicide risk factors and screening In the chronic pain population, risk factors for suicide may be general or pain-specific (TABLE 1).15-21,25 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
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.