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Suicidality in chronic pain: A review of the prevalence, risk factors and psychological links

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This paper reviews and integrates the growing literature concerning the prevalence of and risk factors for suicidality in chronic pain. A series of systematic searches in MEDLINE and PsychINFO identified 12 relevant articles examining suicide, suicide attempts, and suicidal ideation in chronic pain. A selection of theoretical and empirical work identifying psychological processes that have been implicated in both the pain and suicide literature and which may be related to increased suicidality was also reviewed. Relative to controls, risk of death by suicide appeared to be at least doubled in chronic pain patients. The lifetime prevalence of suicide attempts was between 5% and 14% in individuals with chronic pain, with the prevalence of suicidal ideation being approximately 20%. Eight risk factors for suicidality in chronic pain were identified, including the type, intensity and duration of pain and sleep-onset insomnia co-occurring with pain, which appeared to be pain-specific. Helplessness and hopelessness about pain, the desire for escape from pain, pain catastrophizing and avoidance, and problem-solving deficits were highlighted as psychological processes relevant to the understanding of suicidality in chronic pain. Programmatic research is urgently required to investigate the role of both general and pain-specific risk factors for suicidality, to examine how the psychological processes mentioned above mediate or exacerbate suicidality, and to develop enhanced interventions for pain patients at risk.
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REVIEW ARTICLE
Suicidality in chronic pain: a review of the prevalence, risk
factors and psychological links
NICOLE K. Y. TANG
1
* AND CATHERINE CRANE
2
1
Department of Psychology, Institute of Psychiatry, Kings College London, UK;
2
Department of
Psychiatry, University of Oxford, Oxford, UK
ABSTRACT
Background. This paper reviews and integrates the growing literature concerning the prevalence of
and risk factors for suicidality in chronic pain.
Method. A series of systematic searches in
MEDLINE and PsychINFO identified 12 relevant articles
examining suicide, suicide attempts, and suicidal ideation in chronic pain. A selection of theoretical
and empirical work identifying psychological processes that have been implicated in both the pain
and suicide literature and whi ch may be related to increased suicidality was also reviewed.
Results. Relative to controls, risk of death by suicide appeared to be at least doubled in chronic
pain patien ts. The lifetime prevalence of suicide attempts was between 5 % and 14% in individuals
with chronic pain, with the prevalence of suici dal ideation being y20 %. Eight risk factors for
suicidality in chronic pain were identified , including the type, intensity and duration of pain and
sleep-onset insomnia co-occuring with pain, which appeared to be pain-specific. Helplessness
and hopelessness about pain, the desire for escape from pain, pain catastrophizing and avoidance,
and problem-solving deficits were highlighted as psychological processes relevant to the under-
standing of suicidality in chronic pain.
Conclusions. Programmatic research is urgently required to investigate the role of both general and
pain-specific risk factors for suicidality, to examine how the psychological processes mentioned
above mediate or exacerbate suicidality, and to develop enhanced interventions for pain patients at
risk.
INTRODUCTION
Although rates and methods vary, suicide is
endemic throughout the world. In 2002, the
World Health Organization (WHO, 2004) esti-
mated the worldwide number of recorded
suicide deaths to be approximately 873 000 per
year, representing 1
.
8% of all deaths. Prevalence
rates for non-fatal suicide attempts# and suicidal
ideation are far higher. In the USA a recent
population survey indicated that 13
.
5% of
respondents had experienced suicidal ideation in
the past, 4
.
6% having made a suicide attempt
(Kessler et al. 1999). These statistics are both an
index of distress and an indication of a major
management issue. They signify immense
personal suffering and the e conomic costs
associated with lost lives (Clayton & Barcelo,
* Address for correspondence : Nicole K. Y. Tang, D.Phil.,
Department of Psychology, Institute of Psychiatry, King’s College
London, De Crespigny Park, Denmark Hill, London SE5 8AF, UK.
(Email: n.tang@iop.kcl.ac.uk)
# The World Health Organization (1986) defines attempted sui-
cide or parasuicide as: an act with non-fatal outcome in which an
individual deliberately initiates a non-habitual behavior that, with-
out intervention from others, will cause self-harm, or deliberately
ingests a substance in excess of the prescribed or generally recognized
therapeutic dosage, and which is aimed at realizing changes which
the subject desired, via the actual or expected physical conse-
quences’. However, the studies reviewed differ in the definition of
attempted suicide adopted, with many simply asking participants if
they have ever made a suicide attempt’.
Psychological Medicine, 2006, 36, 575–586. f 2006 Cambridge University Press
doi:10.1017/S0033291705006859 First published online 18 January 2006 Printed in the United Kingdom
575
1999) and increased health-care consumption
(O’Sullivan et al. 1999). Despite continuing
research into the risk factors for suicide and
suicidal behaviours, it remains difficult to
predict who is most vulnerable. This is partly
because individuals attempting and completing
suicide represent an extremely heterogeneous
group encompassing (but not restricted to) those
with psychiatric disorders such as depression
or schizophrenia, those with substance misuse
problems or personality disorders, and those
experiencing chronic and debilitating physical
illness. To maximize the potential to identify
those vulnerable to suicide and prevent avoid-
able deaths, there is a need to understand not
only the commonalities across suicidal individ-
uals, but also the unique risk factors that con-
tribute to the development of suicidal ideation
and behaviour in high-risk subgroups.
Chronic pain a high-risk subgroup
Chronic non-malignant pain is a common
health problem, afflicting 1 in every 5 adults
attending primary ca re in any year (Gureje et al.
1998). It is associ ated with poorer physical
health (Eriksen et al. 2003; Mantyselka et al.
2003), lower quality of life (Hagg et al. 2003),
and a higher risk of developing major de-
pression (Ohayon & Schatzberg, 2003; Currie &
Wang, 2004). Given the devastating impact
chronic pain has on the lives of sufferers it has
been glibly suggested when all medical treat-
ment fails, chronic pain patients are left with
limited choice, and committing suicide is one of
seven conceivable solutions to the problem
(Meilman, 1984).
Unfortunately, there is some truth in this
suggestion. A review of the existing literature
suggests that suicidal ideation is rather common
among individuals suffering from chronic
pain. As evident from Part 1 of Table 1, eight
independent studies noted an elevated level of
suicidal ideation in people with chronic pain.
According to three of these studies that con-
trasted the prevalence of suicidality between
people with and without chronic pain, suicidal
ideation was on average three times as common in
chronic pain sufferers relative to non-chronic pain
sufferers (Breslau, 1992; Hinkley & Jaremko,
1994; Magni et al. 1998). While variations in
samples and suicidality assessment method across
studies prevent a collective interpretation of
the ndings, individual studies indicate that the
rate of current suicidal ideation was around
7% among chronic pain in-patients enrolled in
a hospital multidisciplinary rehabilitation pro-
gramme (Fisher et al. 2001) and between 5% and
24% among chronic pain out-patients (Hinkley
& Jaremko, 1994; Treharne et al.2000;Smithet
al.2004a, b). Lifetime prevalence of suicidal
ideation was y20%, with no apparent difference
between a treatment-seeking (Breslau, 1992)
and a community sample (Magni et al.1998).
However, among a group of patients who were
also members of a chronic pain self-help organ-
ization, as many as 50% of these individuals had
seriously considered suicide (Hitchcock et al.
1994, p. 316).
Although existing data concerning suicide
attempts in chronic pain are scant, pain has
been found to contribute directly to 4% of all
deliberate self-harm presentations to general
hospitals in the UK, with 60% of these patients
experiencing pain for 6 months or more
(Theodoulou et al. 2005). Four studies reporting
the prevalence of suicide attempts in chronic pain
samples were identied. As is evident from Part 2
of Table 1, lifetime prevalence of attempted sui-
cide ranged from 5% in people with muscu-
loskeletal pain (Breslau, 1992; Smith et al.2004b)
to 14% in people with chronic abdominal pain
(Magni et al. 1998). Relative to non-chronic pain
sufferers, the rate of suicide attempts was on
average twice as high in people suffering from
chronic pain (Breslau, 1992; Hinkley & Jaremko,
1994; Magni et al.1998).
Concerning the prevalence of completed sui-
cide, an audit of patients at a pain centre in the
USA calculated the rate to be 23/100 000 people
per year (Fishbain et al. 1991). Although this
figure is not as high as in psychiatric popula-
tions, it is nonetheless 2–3 times higher than that
for the general population (Fishbain et al. 1991).
This elevated suicide risk is supported by the
findings from two prospective studies that
have also converged to support the likely link
between pain and suicide; the first, a 10-year
longitudinal study of farmers, found that those
with back pain were nine times more likely to
commit suicide compared to those who were
free of back pain, even when age, smoking, and
social status were controlled for (Penttinen,
1995). The second, an 8-year prospective study,
576 N. K. Y. Tang and C. Crane
Table 1. A summary of the prevalence of suicidal ideation and suicide attempts in chronic non-malignant pain*
Author(s), year,
and country
Sample
size
Recruitment/Data
collection method Sample characteristics Suicidality assessment method
Prevalence
(people with
chronic pain )
Prevalence (controls
without chronic pain)
Part 1. Suicidal ideation
Breslau (1992)
(USA)
128 Recruited from a large health
maintenance organization
Patients with migraine One item from the NIMH Diagnostic
Interview Schedule
a
20
.
6%
(lifetime)
12
.
8%
(lifetime)
Hinkley et al.
(1994) (USA)
241 Consecutive referrals to an out-
patient pain assessment service
Orthopaedic patients (pain
duration o7 months)
One interview item that asked about
current suicidal intention or ideation
5%
(current)
0
.
8%
(current)
Hitchcock et al.
(1994) (USA)
204 Recruited via a national self-
help organization
Individuals with chronic non-
malignant pain
One questionnaire item that asked if
one has seriously considered suicide
50%
(lifetime)
N.R.
Magni et al.
(1998) (USA)
289 Data were drawn from an
epidemiological survey
American Hispanics with
chronic abdominal pain
One item from the NIMH Diagnostic
Interview Schedule
a
21
.
6%
(lifetime)
10
.
6%
(lifetime)
Treharne et al.
(2000) (UK)
123 Recruited from a hospital out-
patient rheumatology clinic
Patients with rheumatoid
arthritis
Items from the Nottingham Health
Profile
11%
(
N.S.)
N.R.
Fisher et al.
(2001) (USA)
200 Recruited from a hospital
multidisciplinary in-patient
rehab programme
Chronic pain patients Beck Depression Inventory Item 9
b
6
.
5%
(current)
N.R.
Smith et al.
(2004a) (USA)
51 Recruited via newspaper and
pain clinic advertisement
Non-cancer chronic pain
patients
Beck Depression Inventory Item 9
b
24%
(current passive)
0%
(current active)
N.R.
Smith et al.
(2004b) (USA)
153 Recruited from a tertiary out-
patient pain centre
Non-malignant pain patients A 42-item Structured Clinical
Interview for Suicide History in
Chronic Pain
19%
(current passive)
18
.
4%
(current active)
N.R.
Part 2. Suicide attempt
Breslau (1992)
(USA)
128 Recruited from a large health
maintenance organization
Patients with migraine One item from the NIMH Diagnostic
Interview Schedule
c
5
.
2%
(lifetime)
2
.
2%
(lifetime)
Hinkley et al.
(1994) (USA)
241 Consecutive referrals to an out-
patient pain assessment service
Orthopaedic patients (pain
duration o7 months)
One interview item that asked about
past suicide attempts
9%
(lifetime)
5
.
6%
(lifetime)
Magni et al.
(1998) (USA)
289 Data were drawn from an
epidemiological survey
American Hispanics with
chronic abdominal pain
One item from the NIMH Diagnostic
Interview Schedule
c
13
.
7%
(lifetime)
5
.
6%
(lifetime)
Smith et al.
(2004b) (USA)
153 Recruited from a tertiary out-
patient pain centre
Non-malignant pain patients A 42-item Structured Clinical
Interview for Suicide History in
Chronic Pain
5
.
3%
(lifetime)
N.R.
* A more detailed table can be viewed online on the Journal’s website (http://journals.cambridge.org/action/displayJournal?jid=PSM).
N.R., Not reported.
a
NIMH, National Institute of Mental Health: Have you ever felt so low you thought of committing suicide? (suicidal ideation).
b
Beck Depression Inventory item 9 is anchored: 0, I do not have any thoughts of killing myself ’; 1, I have thoughts of killing myself but I would not carry them out (passive suicidal
ideation); 2, I would like to kill myself (active suicidal ideation) ; 3 , I would kill myself if I had the chance (active suicidal ideation).
c
Have you ever attempted suicide? (suicide attempt).
Chronic pain and suicide 577
found that patients reporting regional and
widespread body pain had almost twice the risk
of death by accident, violence and suicide
(Macfarlane et al. 2001).
Risks factors for suicide in chronic pain patients
In contrast to the wealth of data available
concerning risk factors predicting future suicide
in general, relatively little is known about
potential risk factors specific to patients with
chronic pain (Fishbain, 1999). To systematically
identify work previously published on this topic,
a series of searches were performed in two elec-
tronic databases (
MEDLINE and PsycINFO) using
each of the keywords suicid*#, parasuicide*,
overdos*, self-harm*, self-injur* together with
chronic pain’, persistent pain’, physical
pain’, back pain’, headache’, musculoskel-
etal pain’, fibromyalgia and arthritis ’. The
searches were limited to articles that reported
original data concerning suicid e risk factors in
chronic pain populations published between
1966 and 2004. However, conference abstracts,
theses, review chapters, case studies, and articles
published in languages other than English were
not included. All returns from the searches
were then assessed, independently, by the
authors for their suitability based on their
titles and abstracts. A total of 12 relevant
articles were identified, reviewed, and compared
to findings in the general suicide literature
(wherever possible). The following section in-
troduces eight risk factors for suicidality in
chronic pain as highli ghted in these studies (see
Table 2 for a summary of the evidence in
support of each of the eight risk factors,
together with methodological details).
General risk factors
Family history of suicide
In line with the wider suicide literature showing a
strong link between family history and current
suicidality (Cheng et al. 2000; Phillips et al.2002;
Runeson & Asberg, 2003), results of one study
(Smith et al.2004b) showed that the risk of
experiencing current suicidal ideation was 7–8
times as high in chronic pain patients with a posi-
tive family history of suicide as in chronic pain
patients without such history, even when other
significant covariates (e.g. depression) were
adjusted for. However, as family history of suicide
is not assessed in other studies, there are no avail-
able data to suggest that it is also a risk factor for
attempted and completed suicide in chronic pain.
Previous suicide attempt
One of the studies reviewed provided evidence
confirming the role of a previous suicide attempt
in the development of subsequent suicidality
in chronic pain, over and above the effect of
depression (Fisher et al.2001).Compared
to depressed but non-suicidal chronic pain pa-
tients, it was found that depressed chronic pain
patients who were experiencing suicidal thoughts
were twice as likely to have made at least one
suicide attempt before (Fisher et al.2001).While
it has been noted in the general suicide literature
that a history of suicide attempt is also a major
risk factor for future suicide attempts (Beautrais,
2001) and completed suicide (e.g. Beautrais, 2001;
Phillips et al. 2002), it is unclear to what extent
this is also the case in chronic pain.
Being female
Two of the studies reviewed suggested that,
relative to male chronic pain sufferers, female suf-
ferers were more vulnerable to suicidal idea-
tion (Treharne et al. 2000) and death by suicide
(Timonen et al. 2003). These are interesting find-
ings given the fact that in the western world deaths
by suicide are far more common in men (Williams,
2001). However, care must be taken when inter-
preting these data as in two other studies with
relatively smaller samples of pain clinic patients
(Smith et al.2004a, b), the association between
gender and suicidality did not reach statistical
significance. Moreover, it is possible that the
higher vulnerability to suicidality in female pain
sufferers is inflated by an overrepresentation of
females in the sampled population (rheumatoid
arthritis) (Riise et al.2000).
Presence of co-morbid depression
Four of the studies reviewed provided consistent
evidence in support of the role of depression
in augmenting the risk of suicidal ideation and
suicide attempt among patients with chronic pain
(Breslau, 1992; Magni et al. 1998; Treharne et al.
2000; Fisher et al. 2001; Timonen et al.2003).
While this is not a surprising finding given the
# An asterisk (*) indicat es truncation of keywords.
578 N. K. Y. Tang and C. Crane
Table 2. A summary of the evidence for the risk factors predicting suicidality in chronic non-malignant pain*
Risk factor
For the
prediction
of Source of evidence
Sample size and
characteristics
Suicidality assessment
method Brief summary of results
1 Family history
of suicide
Suicidal
ideation
Smith et al.
(2004b) (USA)
n=153 chronic pain
out-patients
Structured Clinical Interview
for Suicide History
Positive family history of suicide attempts/completions associated
with greater likelihood of current suicidal ideation (AOR=7–8)
2 Previous suicide
attempt
Suicidal
ideation
Fisher et al. (2001)
(USA)
n =39 chronic pain
in-patients
Beck Depression Inventory
Item 9
a
Previous suicide attempt more likely in depressed/suicidal patients
(54%) compared to depressed/non-suicidal (23 %)
3 Being
female
Suicidal
ideation
Treharne et al.
(2000) (UK)
n=123 hospital RA
out-patients
Items from the Nottingham
Health Profile
More female RA patients (14 %) reported suicidal ideation than male
RA patients (3%)
Being
female
Completed
suicide
Timonen (2003)
(Finland)
n=1585 suicide
victims
Official death certificate Females over-represented among RA patients who committed suicide
(53% RA women v. 17% women with neither RA nor OA)
4 Co-morbid
depression
Suicidal
ideation
Breslau (1992)
(USA)
n=1007 young
adults
Item from NIMH Diagnostic
Interview Schedule
b
MDD in migraine with aura increased odds for suicidal ideation
(AOR=19
.
6) compared to migraine with aura alone (AOR=2
.
4) and
MDD alone (AOR=7
.
4). Similar results for migraine without aura
Co-morbid
depression
Suicidal
ideation
Treharne et al.
(2000) (UK)
n=123 hospital RA
outpatients
Items from Nottingham
Health Profile
Suicidal ideation more common in depressed RA patients (30%) than
those who were not (7 %)
Co-morbid
depression
Suicide
attempt
Breslau (1992)
(USA)
n=1007 young adults Item from NIMH Diagnostic
Interview Schedule
c
MDD in migraine with aura increased odds for suicide attempt
(AOR=23
.
2) compared to migraine with aura alone (AOR=4
.
3) and
MDD alone (AOR=7
.
8). Similar results for migraine without aura
Co-morbid
depression
Completed
suicide
Timonen et al.
(2003) (Finland)
n=1585 suicide
victims
Official death certificate Co-morbid depressive disorders preceded suicides in 80% female RA
patients, compared to 31% in those with OA and those with neither RA
nor OA
5 Location and
type of pain
Suicidal
ideation
Breslau (1992)
(USA)
n=1007 young adults Item from NIMH Diagnostic
Interview Schedule
b
Migraine with aura alone associated with increased odds (AOR=2
.
4)
for suicidal ideation, compared to migraine without aura (AOR=1
.
7)
Location and
type of pain
Suicidal
ideation
Smith et al.
(2004b) (USA)
n=153 chronic pain
out-patients
A 42-item Structured
Clinical Interview for
Suicide History
Abdominal pain linked to a 4- to 6-fold greater risk of suicidal ideation,
neuropathic pain associated with a lessened risk
Location and
type of pain
Suicide
attempt
Breslau (1992)
(USA)
n=1007 young
adults
Item from NIMH Diagnostic
Interview Schedule
c
Migraine with aura alone associated with increased risk (AOR=4
.
3) for
suicide attempt, compared to migraine without aura (AOR=2
.
7)
Location and
type of pain
Suicide
attempt
Magni et al. (1998)
(USA)
n=289 people with
chronic abdominal
pain
Item from NIMH Diagnostic
Interview Schedule
c
Suicide attempt rate 2–3 times higher in those with chronic abdominal
pain compared to those without
Location and
type of pain
Completed
suicide
Penttinen (1995)
(Finland)
n=4199 male
farmers
Official death certificate Nine times greater risk of suicide in farmers with back pain at 10-yr follow-up
than those without back pain, controlling for age, smoking and social status
Location and
type of pain
Completed
suicide
Macfarlane et al.
(2001) (UK)
n=6569 individuals Office for National Statistics
data
Regional and widespread pain associated with 3 and 5 times risk of
death by accidents, suicide, or violence at 8-yr follow-up
6 High pain
intensity
Suicidal
ideation
Smith et al.
(2004a) (USA)
n=51 chronic pain
out-patients
Beck Depression Inventory
Item 9
a
High pain intensity was one of two discriminators of the
presence/absence of PSI (p<0
.
001)
7 Long pain
duration
Suicidal
ideation
Hinkley et al.
(1994) (USA)
n=635 chronic pain
out-patients
Interview item that asked
about current suicidal
intention or ideation
Greater proportion of long-duration pain patients experienced current
suicidal ideation, compared to patients with shorter pain duration (p<0.05)
Long pain
duration
Suicidal
ideation
Treharne et al.
(2000) (UK)
n=123 hospital RA
out-patients
Items from the Nottingham
Health Profile
Suicidal ideation was more likely if RA>4 yr (12 %) compared with
RA<2yr(7%)
8 Co-morbid
insomnia
Suicidal
ideation
Smith et al.
(2004a) (USA)
n=51 chronic pain
out-patients
Beck Depression Inventory
Item 9
a
Sleep-onset insomnia was one of two discriminators of the
presence/absence of PSI (p<0
.
001)
* A more detailed table can be viewed online on the Journal’s website (http://journals.cambridge.org/action/displayJournal?jid=PSM).
AOR, Adjusted odds ratio; RA, rheumatoid arthritis ; OA, osteoarthritis ; MDD, major depressive disorder; PSI, passive suicidal ideation.
a
Beck Depression Inventory item 9 is anchored: 0, I do not have any thoughts of killing myself’; 1, I have thoughts of killing myself but I would not carry them out (passive suicidal ideation) ; 2, I would
like to kill myself (active suicidal ideation) ; 3, I would kill myself if I had the chance (active suicidal ideation).
b
NIMH, National Institute of Mental Health: Have you ever felt so low you thought of committing suicide? (suicidal ideation).
c
Have you ever attempted suicide? (suicide attempt).
Chronic pain and suicide 579
high co-morbidity between pain and depression
(Dworkin & Gitlin, 1991; Fisher et al. 1997) and
between depression and suicide (Harris &
Barraclough, 1997; Kessler et al. 1999; Yen et al.
2003), it is worth noting that depression does not
always predict suicidality in chronic pain (Smith
et al.2004b) and that there is a subset of chronic
pain patients who are depressed but not suicidal
(Fisher et al.2001).
Pain-specific risk factors
Location and type of pain
There is some evidence suggesting that the
location and type of pain may have implications
for the risk of suicidality. In relation to the
location of pain, the presence of back pain
(Penttinen, 1995) and widespread body pain
(Macfarlane et al. 2001) were associated with a
higher risk of future death by suicide, compared
to pain-free individuals. In relation to the type
of pain, pains of different qualities and charac-
teristics appeared to have differential power in
predicting suicidality. For instance suicidal
ideation and suicide attempts were found to be
twice as common in migraine with aura as in
migraine without aura, regardless of the pres-
ence of co-morbid depression (Breslau, 1992).
Suicidal ideation was more prominent among
people reporting chronic abdominal pain,
whereas people diagnosed with neuropathic
pain wer e less likely to experience suicidal idea-
tion (Magni et al. 1998; Smith et al. 2004 b).
Finally a study by Amir et al. (2000) found an
overall elevation on a measure of suicidal risk in
a mixed group of patients with chronic pain,
when compared to controls, but identified no
difference between patients with fibromyalgia
and controls when these individuals were
examined separately. Together, these findings
highlight the importance of studying the effect of
various subtypes of pain on suicidality individ-
ually. In particular, it will be of theoretical and
clinical interest to investigate in future research
why certain types of pain (e.g. back pain,
abdominal pain) promote the risk of suicide
whereas others (e.g. neuropathic pain) do not.
High pain intensity
Although it seems logical to assume that the
amount of pain an individual suffers from is
proportional to the degree of suicidal ideation or
behaviour exhibited, evidence drawn from studies
testing this assumption is not so clear-cut. Of the
two studies reviewed that examined pain intensity
and suicidality, one noted a significant positive
relationship (Smith et al.2004a) whereas the
other found pain severity to be independent of
suicidal ideation (Smith et al.2004b). Clearly,
more research is required to clarify the role of pain
intensity in manifesting suicide risk.
Long pain duration
There is some initial evidence indicating that the
longer the pain duration, the more likely it is for
a patient to experience suicidal ideation. In the
first study by Hinkley & Jarem ko, (1994), it
was noted that patients who had a longer pain
duration (>3 months) differed from those who
had a shorter pain duration (<3 months) on
a range of psychological variables, including
having a greater likelihood of experiencing
suicidal ideation. In the second study by Treharne
et al. (2000), it was found that the risk of experi-
encing suicidal ideation was greater in patients
with longstanding rheumatoid arthritis compared
to those with early rheumatoid arthritis.
Presence of co-morbid insomnia
One of the studies reviewed (Smith et al.2004a)
highlighted sleep-onset insomnia as one of two
significant discriminators of the presence and
absence of suicidal ideations in chronic pain
patients. Specifically, it was found that patients
who reported severe and frequent sleep-onset
insomnia with concomitant daytime dysfunction
and high pain intensity were more likely than
those with none of these problems to report
suicidal ideation, even when the effect of
depression was controlled for. Sleep-onset
insomnia severity alone explained 67% of
the variance accounted for. These findings are
consistent with previous research showing a
higher prevalence of sleep disturbance in suicidal
than non-suicidal individuals (Singareddy &
Balon, 2001) and underscore the importance of
studying the interaction between pain-specific and
non-pain-specific risk factors when investigating
suicidality among chronic pain patients.
Limitations
The studies considered here have taken the first
important step towards delineating risk factors
580 N. K. Y. Tang and C. Crane
associated with suicidality in chronic pain.
However, it is obviou s that the amount of
evidence accrued for each risk factor is rather
limited. In terms of predicting suicidality, most
studies focused on suicidal ideation rather than
suicide attempts or completed suicide. While
suicidality can be conceptualized as a process
that starts with fleeting suicidal thoughts and
then evolves through more concrete plans to
suicide attempt and finally completed suicide, it
is important to note that risk factors that predict
suicidal ideation may not necessarily predict
a subsequent suicide attempt or completed
suicide. Further, the studies that have been
conducted to date suffer from a number of
methodological limitations, which restrict the
conclusions that can be drawn. The most
important of these are outlined as follows.
First, the majority of the studies reported
used questionnaire measures of suicidality, with
several relying on single items to determine rates
of suicidal ideation or behaviour (e.g. Treharne
et al. 2000 ; Fisher et al. 2001 ; Smith et al.
2004a), and others simply asking individuals
whether they had ever made a suicide attempt
(Hinkley & Jaremko, 1994; Hitchcock et al.
1994). While such questions have face validity,
their reliability in reflecting a person ’s current
suicidal intentions and past suicidal ideation
and behaviour is unknown. Although a similar
pattern of elevated suicidal risk in chronic pain
individuals has been observed in other studies
using validated multi-item scales to measure
suicidality (e.g. Amir et al. 2000 ; Smith et al.
2004b), in order to draw parallels between
research on suicidality in chronic pain and
research in the broader suicide literature it
would be beneficial for future studies to adopt
more rigorous methods of assessment, for
example incorporating the widely used Beck
scales to assess suicidality (Beck et al. 1979).
A second important limitation concerns the
fact that, apart from a handful of prospective
population-based studi es (e.g. Penttinen, 1995 ;
Macfarlane et al. 2001; Timonen et al. 2003),
most of the research reviewed has examined
suicidality in chronic pain retrospectively. This
introduces the risk of self-reporting errors, recall
bias, and memory failure. Additionally because
the timing of first onset of suicidality relative to
the onset of pain has rarely been assessed, a
causal relationship between chronic pain and
suicidality cannot be inferred (e.g. Breslau,
1992; Magni et al. 1998 ; Smith et al. 2004a).
It is likely that at least part of the association
between suicidality and chronic pain results
from the inclusion of individuals experiencing
chronic pain in the context of pre-existing and
longstanding psychiatric or substance misuse
problems. Future research should consider
conducting a form al psychiatric assessment
excluding patients with co-morbid psycho-
pathology.
Third, studies to date have not adequately
addressed the issue of the extent to which
increased risk of suicidality is a fun ction of pain,
per se, as opposed to the disability that pain
produces. Although pain has unique character-
istics that make it particularly likely to provoke
suicidal ideation (e.g. its ability to capture
attention, interrupt ongoing activities and be
physically unbearable, see The desire for escape
from pain section below) it also has common-
alities wi th other disabling conditions (e.g.
physical limitations, stigma). Studies comparing
rates of suicidality in individuals matched for
levels of functional impairment, but suffering
from chronic painful versus non- painful con-
ditions would go some way towards determining
the extent to which increased suicidality in
chronic pain populations is pain-specific.
Finally, several studies have not controlled
for the range of social and demographic factors
that are likely to distinguish chronic pain
patients from the general population (e.g. older
age, financial hardship, unemployment). Since
these variables may independently confer
increased suicide risk (Williams, 2001), their
omission is problematic and should be borne in
mind when interpreting the existing findings.
Similarly, while several studies have identified
risk fact ors for suicidality in chronic pain after
controlling for level of depression (e.g. Breslau,
1992; Fisher et al. 2001; Smith et al. 2004 a)
most have not done so. More systematic
research is required to isolate the effect of pain
on suicidality from these variables, as well as to
understand the mechanisms by which pain inter-
acts with these factors to increase suicide risk.
Although the existing literature suffers from
some limitations, the findings of studies to date
do indicate that the suicidality in chronic pain is
an important issue in need of further investi-
gation. In the following section we discuss how
Chronic pain and suicide 581
different aspects of pain experience may increase
risk of suicidality, drawing on existing under-
standing of the psychological processes involved.
The aim is not to provide an exhaustive review
of psychological theories of suicidality or the
psychological consequences of chronic pain, but
to highlight points of overlap and areas that may
be worthy of future research and to shed light on
the mechanisms through which physical pain
might evolve into psychological pain, informing
clinical interventions for patients distressed by
chronic pain.
Helplessness and hopele ssness about pain
Helplessness, the conviction that nothing can be
done to change an undesirable situation and
hopelessness, the expectation that desirable
outcomes will never occur (Seligman, 1975 ;
Abramson et al. 1989), are common experiences
in patients struggling with chronic pain. Indeed,
previous articles have quoted patients expres-
sion of their frustration verbatim, [the] pain is
now beyond coping with and if [doctors] say
they can’t do anything I don’t know what I’m
going to do, sometimes I just want to quit taking
everything ’cause it doesn’t seem like anything’s
working (Seers & Friedli, 1996 ; Thomas, 2000).
In the general suicide literature, findings drawn
from a number of cross-sectional and longi-
tudinal studies have attested to the role of
hopelessness in the developm ent of suicidal
ideation and behaviour (e.g. Minkoff et al. 1973;
Beck et al. 1975, 1985; Dyer & Kreitman, 1984)
and this is mirrored in the finding that pain
patients themselves attribute their suicidal
thoughts to hopeless feelings associated with
pain (Hitchcock et al.1994).Itseemsplausible
to hypothesize that the relationship between
chronic pain and suicidality may be at least
partially mediated by helplessness/hopelessness
about the ability to cope and about the chances
of future relief from pain. Previous studies have
linked helplessness to the development of func-
tional disability (Nicassio et al.1993),co-morbid
depression (Hommel et al. 1998) and anxiety
(Lindroth et al. 1994), as well as higher rates of
early mortality (Callahan et al. 1996) in rheuma-
toid arthritis patients. However, research has yet
to systematically examine whether helplessness/
hopelessness about pain is in fact linked to
increased suicidality after controlling for co-
morbid depression, and the extent to which
helplessness/hopelessness mediates associations
between pain-related variables and suicidal idea-
tion and behaviour. Since helplessness/hope-
lessness has repeatedly been linked to suicidality
in the broader literature and may be amenable to
psychological interventions future research in this
area is called for.
The desire for escape from pain
The desire for escape from an unbearable situ-
ation is one of the most commonly reported
motivations for suicidal behaviour (Hjelmeland
et al. 2002). Indeed it has repeatedly been sug-
gested that both suicide and suicidal behaviour
can be viewed in terms of an attempt to escape
from aversive self-consciousness (Baumeister,
1990), unbearable psychache (Shneidm an,
1997) or intolerable situations in which the
opportunity to escape or to receive relief are
perceived to be remote (e.g. Williams & Pollock,
2000; Williams, 2001). These conceptualizations
may be pertinent to the understanding of
suicidality in chronic pain since, by virtue of its
intrusive and attention-demanding character-
istics (Eccleston & Crombez, 1999), pain is
particularly difficult to escape’. Pain’s capacity
to disrupt thoughts, activities and even sleep
renders most forms of temporary respites
ineffectual (Thomas, 2000). For some patients,
pain may become so acute that it is unbearable
and they perceive their future to be an eternity
of suffering’, pill after pill after pill as Thom as
(2000) reported. It is unclear which factors fuel
the desire to escape and result in suicide being
regarded as a viable means of terminating
suffering, but it has been suggested that the
feelings of defeat and entrapment play a key role
(Williams et al. 2005). The authors are currently
investigating the role of mental defeat in chronic
pain and the role of entrapment in suicidal
behaviour. Moreover, the link between pain-
related insomnia and suicidality may also help
explain suicidality within this framework as
difficulty in sleeping removes one of the only
respites from pain, potentially increasing
desperation and exacerbating suicidal ideation
further.
Pain catastrophizing and avoidance
Pain catas trophizing (a form of extremely
negative thinking repres ented by a person
taking the view that pain or a situation related
582 N. K. Y. Tang and C. Crane
to pain will lead to or is associated with a
physical or mental catastrophe) and pain
avoidance (the tendency to avoid engaging
with or to try to escape from potentially pain-
provoking activities or situations) are two
psychological responses to pain that have
received considerable research attention and
which may be associated with increased risk of
suicidality. It is certainly possible, in some
patients, to identify a progression from catas-
trophic interpretation of pain and its conse-
quences, to negative emotions, and then to the
desire to escape throu gh suicide. For example in
Seers & Friedli (1996), a patient overwhelmed
by the pain revealed his/her suicidality as
follows: [pain] has stopped me leading my
whole life. I’m petrified [doctors]’ll say I have to
learn to live with this level of pain. Pain is 90/
100. I feel I would rather die. I’d like to be un-
conscious. Deep inside I feel suicidal. Do I really
want to see tomorrow ? Can’t see through the
pain when there is so much and I know I do not
want to live with it.’ While the direct association
between pain catastrophizing and suicidal idea-
tion awaits empirical confirmation, it is under-
stood that catastrophizing about pain amplifies
pain experience, increases consumption of an-
algesics medication, worsens social and occu-
pational functioning, and intensifies negative
emotions (see Sullivan et al. 2001 for a revie w).
Given the link between increased pain intensity
and suicidality (Smith et al. 2004a) and between
depression and suicidality (Breslau, 1992), pain
catastrophizing forms a logical target for inter-
vention.
Problem-solving deficits
Adapting to a life with chronic pain is no easy
task and individuals requires a huge amount of
effort to deal with problems secondary to the
pain, such as potential financial loss [‘I’m
worried I’ll lose my job as off sick. Try to keep
working even when feel really ill (Seers &
Friedli, 1996, p. 1165)] and added strain on social
and family lives [‘Pain separates you. It’s really
hard to be involved with people when you’re in
pain (Thomas, 2000, p. 692), Husband too
drained to be sympathetic. Children affected by
it don’t do things physically with them. They
treat me as fragile. I have cheated him of a nor-
mal life (Seers & Friedli, 1996)]. Frequently,
patients need to make marked adjustments to life
goals and priorities in order to live with the
pain. In the general suicide literature it has been
suggested for some time that deficits in problem-
solving abilities represent an important psycho-
logical risk factor in suicidal behaviour (see
Pollock & Williams, 1998 for a review) and more
recent research suggests that suicidal individuals
also have greater difficul ties in making specific
plans of how to achieve desired goals in the
future (Vincent et al. 2004). To date research
has not examined whether suicid ality in pain is
linked to difficulties in solving pain-related
problems or planning for the future, although
poor perceived problem-solving skill has been
linked to higher ratings of pain unpleasa ntness,
disability, level of depression and hopelessness in
patients with low back pain (Witty et al. 2001).
However given the central role of problem-solv-
ing deficits in the psychological profile of suicidal
patients more generally, the great demand that
pain is likely to place on these skills and the po-
tential use of problem-solving therapies as an
intervention, this is likely to be an important area
for future research.
Implications
The findings of the literature reviewed above
have at least three implications for the under-
standing and management of suicidality in the
chronic pain population.
Clinical audit
It has become clear that direct and precise
information about suicide in chronic pain is
often unavailable. This to some extent reflects a
lack of concern and to some extent the absence
of an infrastructure to facilitate the systematic
collection of relevant data. Regular audit, both
locally at individual pain centres, and aggregated
across pain clinics, would provide precious data
not only concerning the current status of the
problem, but also aiding the identification of
new short- an d long-term predictors of suicide
not investigated by previous research (Hawton &
Morgan, 1994). In addition, it is likely that the
introduction of regular clinical audit would
accelerate the development of routine manage-
ment of suicidal risk in pain clinics, optimizing
staffs capacity to effectively detect and handle
acute suicidal risk in pain patients presenting
for treatment.
Chronic pain and suicide 583
Limiting means of suicide
Taking drug overdose remains as the common-
est (75%) method of suicide among chronic
pain patients who have survived a previous
suicide attempt (Smith et al. 2004 b). Since these
patients are often prescribed analgesics and
tricyclic antidepressants for pain relief (McQuay
& Moore, 1997), they may have ready access to
drugs which are dangerous in overdose.
Considering that the rates of suicidal behaviour
are, to a certain extent, influenced by the avail-
ability of lethal means (e.g. Hawton et al. 2001,
2004), it seems sensible for clinicians to ha ve a
careful assessment of their pain patients’ mental
state (including the presence of any suicidal
thinking) in order to inform prescribing de-
cisions (e.g. Theodoulou et al. 2005).
Developing psychological interventions for
suicidality in chronic pain
The current review has drawn attention to the
role played by several pain-specific risk factors
and a number of psychological processes that
may be involved in the escalation of suicidality
in patients with chronic pain. Several of these
variables, namely sleep-onset insomnia, hope-
lessness, catastrophizing and avoidance, goal
adjustments and problem-solving, are amenable
to psychological intervention. In fact, there are
existing treatments with proven efficacy that
target these factors both in chronic pain and in
other clinical groups (e.g. Salkovskis et al. 1990 ;
Linehan et al. 1993 ; Hayes et al. 1999 ; Segal
et al. 2002; McCracken et al. 2005). Program-
matic research is now called for to investigate
the extent to which interventions targeting these
psychological factors are able to improve our
capacity to reduce suicide risk among the most
distressed chronic pain patients.
ACKNOWLEDGEMENTS
Nicole Tang is a Research Fellow of the Croucher
Foundation Hong Kong. Catherine Crane is a
Wellcome Trust Post-doctoral Research Psy-
chologist. We thank Professor Paul Salkovskis
for his very helpful comments on an earlier draft
of this manuscript. This work was supported in
part by the Wellcome Trust GR067797.
DECLARATION OF INTEREST
None.
NOTE
Supplementary information accompanies this
paper on the Journal’s website (http://journals.
cambridge.org).
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of prospective suicide attempts : findings from the collaborative
longitudinal personality disorders study. Journal of Abnormal
Psychology 112, 375–381.
586 N. K. Y. Tang and C. Crane
... In addition to the mental health conditions associated with an increased risk of suicide, certain physical health conditions such as chronic pain and chronic medical conditions have also been shown to be associated with increased SI and suicide attempts [27][28][29][30][31]. Approximately 20% of the individuals with chronic pain endorse SI [28], while 48% of the patients with fibromyalgia endorse SI [32]. ...
... In addition to the mental health conditions associated with an increased risk of suicide, certain physical health conditions such as chronic pain and chronic medical conditions have also been shown to be associated with increased SI and suicide attempts [27][28][29][30][31]. Approximately 20% of the individuals with chronic pain endorse SI [28], while 48% of the patients with fibromyalgia endorse SI [32]. Those with >1 chronic medical conditions have similarly elevated rates of SI, with 35% of those with ≥2 conditions endorsing lifetime SI [30]. ...
Article
Background Suicide is a leading cause of death in the United States, and suicidal ideation (SI) is a significant precursor and risk factor for suicide. Objective This study aimed to examine the impact of a telepsychiatric care platform on changes in SI over time and remission, as well as to investigate the relationship between various demographic and medical factors on SI and SI remission. Methods Participants included 8581 US-based adults (8366 in the treatment group and 215 in the control group) seeking treatment for depression, anxiety, or both. The treatment group included patients who had completed at least 12 weeks of treatment and had received a prescription for at least one psychiatric medication during the study period. Providers prescribed psychiatric medications for each patient during their first session and received regular data on participants. They also received decision support at treatment onset via the digital platform, which leveraged an empirically derived proprietary precision-prescribing algorithm to give providers real-time care guidelines. Participants in the control group consisted of individuals who completed the initial enrollment data and completed surveys at baseline and 12 weeks but did not receive care. Results Greater feelings of hopelessness, anhedonia, and feeling bad about oneself were most significantly correlated (r=0.24-0.37) with SI at baseline. Sleep issues and feeling tired or having low energy, although significant, had lower correlations with SI (r=0.13-0.14). In terms of demographic variables, advancing age and education were associated with less SI at baseline (r=−0.16) and 12 weeks (r=−0.10) but less improvement over time (r=−0.12 and −0.11, respectively). Although not different at baseline, the SI expression was evident in 34.4% (74/215) of the participants in the control group and 12.32% (1031/8366) of the participants in the treatment group at 12 weeks. Although the participants in the treatment group improved over time regardless of various demographic variables, participants in the control group with less education worsened over time, after controlling for age and depression severity. A model incorporating the treatment group, age, sex, and 8-item Patient Health Questionnaire scores was 77% accurate in its classification of complete remission. Those in the treatment group were 4.3 times more likely (odds ratio 4.31, 95% CI 2.88-6.44) to have complete SI remission than those in the control group. Female participants and those with advanced education beyond high school were approximately 1.4 times more likely (odds ratio 1.38, 95% CI 1.18-1.62) to remit than their counterparts. Conclusions The results highlight the efficacy of an antidepressant intervention in reducing SI, in this case administered via a telehealth platform and with decision support, as well as the importance of considering covariates, or subpopulations, when considering SI. Further research and refinement, ideally via randomized controlled trials, are needed.
... Secondary emotional and psychological effects such as depression, anxiety, and suicidal ideation have been known to increase in manifestation in chronic pain patients when compared to the general population or have been known to be observed concomitantly (Costanza et al., 2021;Gallagher et al., 1995;Narita et al., 2006;Okifuji & Benham, 2011;Racine, 2018). Risk of attempt for suicide and completed death by suicide was also found in one review as being at least doubled for those suffering from chronic pain conditions when compared to the general population (Hitchcock et al., 1994;Magni et al., 1998;Tang & Crane, 2006). A recent study (Costanza et al., 2021) involving a cohort of chronic pain patients within a pain center in Switzerland found that a described psychological construct used in assessing risk for suicide, known as "meaning in life (MiL)" (Frankl, 1985;Heisel & Flett, 2016), may be eroded in individuals experiencing chronic pain. ...
Article
Abnormal pain affects ~50 million adults nationwide. With many of the current treatment options for chronic pain, such as opioid analgesics, carrying side effects such as the threat for addiction, research into safer and more effective options for chronic pain relief is crucial. Abnormal alterations in nociceptive sensitivity, which is the sensitivity of peripheral sensory neurons that detect noxious stimuli, can underlie, and perpetuate chronic pain. However, much is still unknown about the mechanism of how these abnormal alterations in sensitivity occur. To help elucidate genetic components controlling nociceptive sensitivity, the Drosophila melanogaster larval nociception model has been used to characterize well-conserved pathways through the use of genetic modification and/or ultraviolet (UV) irradiation injury to alter the sensitivity of experimental animals. We have continued to build upon this knowledge to reveal a more complete system for how nociceptive sensitivity can be altered, even without injury, by investigation into the potential roles of other novel genes/signaling pathways including, Arm, a component within the Wnt/Wg signaling pathway. Our findings indicate Arm to be a facilitator in controlling nociceptive sensitivity in the absence of injury, by maintaining baseline sensitivity. In an effort to also explore the mechanisms of the primary nociceptors (nociceptors which directly detect noxious stimuli), we conducted bioinformatic analysis of RNA transcripts derived specifically from the nociceptors of larvae after UV injury. Results from this effort led to the discovery of a downregulation in serine proteases during peak allodynia (when something not normally noxious becomes so) development. Results also led to the hypothesis that upregulated Rgk1 and AnxB11 were involved in recovery of the nociceptor from hyperalgesia. This was supported by the knockdown of Rgk1 and AnxB11 having led to nociceptor hypersensitivity in larvae. And in an effort to move the methodology of our field forward, and because the larval stages of fruit fly development are relatively brief, we developed a methodology that allows longer term experimentation of nociceptive sensitization after injury in adult fruit flies. Ultimately, our research uncovered components involved in nociceptive sensitivity, which will hopefully lead to uncovering better treatment options for abnormal pain in the future.
... In 2015, a systematic review of 38 studies reported rates of misuse ranging from 21% to 29% and rates of addiction from 8% to 12% (Vowles et al., 2015). Regarding suicide, in 2006, an integrative review of the literature conducted by Tang and Crane reported a lifetime prevalence of suicide attempts that ranged between 5% and 14% and a prevalence of suicidal ideation of 20% among individuals suffering from chronic pain (Tang and Crane, 2006). These data confirm the irrefutable relevance of chronic pain as a global public health concern. ...
Article
Full-text available
Anhedonia is the diminished motivation and sensitivity to pleasurable stimuli. It has been reported to be more prevalent in patients with chronic pain as compared to healthy controls. Endometriosis is a chronic inflammatory systemic disease with a significant psychosocial impact that compromises wellbeing and the day-to-day life of patients. Women with endometriosis show significant psychological distress, even more pervasive when chronic pelvic pain is present. In the current review we will discuss the role of anhedonia in endometriotic chronic pelvic pain. We will also present new lines of research that could lead to more fully clarifying the psychological impact of endometriosis and its detrimental repercussions to quality of life and mental health.
... Risk of SD was at least doubled in patients with chronic pain compared to those without [59]. Consistent with prior studies predicting suicide-related outcomes in general populations, common suicide risk factors for patients with pain conditions identified in our review included depressive disorders, unspecified physical or somatic pain conditions, and anxiety disorders. ...
Article
Full-text available
Suicide is a leading cause of death in the US. Patients with pain conditions have higher suicidal risks. In a systematic review searching observational studies from multiple sources (e.g., MEDLINE) from 1 January 2000–12 September 2020, we evaluated existing suicide prediction models’ (SPMs) performance and identified risk factors and their derived data sources among patients with pain conditions. The suicide-related outcomes included suicidal ideation, suicide attempts, suicide deaths, and suicide behaviors. Among the 87 studies included (with 8 SPM studies), 107 suicide risk factors (grouped into 27 categories) were identified. The most frequently occurring risk factor category was depression and their severity (33%). Approximately 20% of the risk factor categories would require identification from data sources beyond structured data (e.g., clinical notes). For 8 SPM studies (only 2 performing validation), the reported prediction metrics/performance varied: C-statistics (n = 3 studies) ranged 0.67–0.84, overall accuracy(n = 5): 0.78–0.96, sensitivity(n = 2): 0.65–0.91, and positive predictive values(n = 3): 0.01–0.43. Using the modified Quality in Prognosis Studies tool to assess the risk of biases, four SPM studies had moderate-to-high risk of biases. This systematic review identified a comprehensive list of risk factors that may improve predicting suicidal risks for patients with pain conditions. Future studies need to examine reasons for performance variations and SPM’s clinical utility.
... Furthermore, those suffering cLBP report harmful effects on their exercise, sex life, social life, work relationships, and family relationships [16,17]. Many studies have also reported tangential findings including decreased sleep quality and increased suicide in patients with cLBP [18][19][20][21]. ...
Article
Chronic low back pain is a global socioeconomic crisis compounded by an absence of reliable, curative treatments. The predominant pathology associated with chronic low back pain is degeneration of intervertebral discs in the lumbar spine. During degeneration, nerves can sprout into the intervertebral disc tissue and be chronically subjected to inflammatory and mechanical stimuli, resulting in pain. Pain arising from the intervertebral disc, or disc-associated pain, is a complex, multi-faceted disorder which necessitates valid animal models to screen therapeutics and study pathomechanisms of pain. While many research teams have created animal models of disc degeneration, the translation of these platforms to disc-associated pain models has been limited by an absence of chronic pain-like behavior. Further, the few models which measure disc-associated pain-like phenotypes have been established in mice, which are not amenable to surgical treatment procedures due to their small size. This deficiency drives the need for a new model of disc-associated pain where pain-like behavior is measurable and intervertebral discs are large enough for surgical procedures. These criteria promote rats as the optimal platform for a disc-associated model of chronic low back pain. Herein, a rat model of disc-associated pain is described that displays chronic pain-like behavior, overt disc degeneration, and nerve sprouting in the intervertebral disc. In addition to the model, a novel method for measuring disc degeneration real-time, non-invasively, is delineated which exhibits remarkable precision and accuracy. Finally, a next generation treatment, derived from decellularized, porcine nucleus pulposus tissue is described which is injectable, thermally fibrillogenic, and cytocompatible. In the rat model of disc-associated pain, this biomaterial restores degenerated disc volume and dramatically decreases pain-like behavior. In summary, this dissertation describes the development of a method for quantifying degeneration real-time, establishes a rat model of disc-associated pain, and successfully treats disc-associated pain in this model with a next-generation biomaterial. Advisor: Rebecca Wachs
Article
Objectives The association among psychiatric treatment history, HIV, and suicide reattempts among people starting treatment for substance use is not well understood. The objective of this study was to describe, by HIV status, the risk and protective factors associated with suicide reattempts among adults seeking treatment for substance use. Methods The study included 340 390 US adult residents aged ≥18 years in the Addiction Severity Index–Multimedia Version network from January 1, 2014, through December 31, 2020. We used adjusted logistic regression models to estimate strength of association between prior psychiatric treatment, HIV status, and sociodemographic factors and suicide reattempts within 30 days of treatment evaluation. Results Adults who had been prescribed psychiatric medication were less likely to have a recent suicide reattempt (adjusted odds ratio [aOR] = 0.8; 95% CI, 0.7-0.8) than adults with no prescription history. Adjusted models found similar protective effects between psychiatric treatment and suicide reattempts among adults reporting abuse, mental illness, injection drug use, and limited activity because of a medical condition. Conversely, the following were associated with recent suicide reattempts: being male (aOR = 1.4; 95% CI, 1.3-1.5), having a high school education/GED (General Educational Development) or less (aOR = 1.2; 95% CI, 1.1-1.2), being single (aOR = 1.2; 95% CI, 1.1-1.3), experiencing a pain problem (aOR = 1.2; 95% CI, 1.2-1.3), and not being referred to substance use treatment by court (aOR = 3.4; 95% CI, 3.2-3.7). Conclusions A history of prescribed psychiatric medication is significantly associated with a reduced risk for suicide reattempts among adults seeking substance use treatment. Clinicians should consider incorporating mental health and suicide assessments into substance use treatment plans.
Article
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Background Rates of suicide and unintended overdose death are high among midlife and older women, yet there is paucity of data identifying women at greatest risk. Psychoactive medications, commonly prescribed and co-prescribed in this population, may serve as salient indicators of risk for these outcomes. Objective To determine whether long-term psychoactive medications and psychoactive polypharmacy predict risk of suicide and unintended overdose death among midlife and older women Veterans above and beyond other recognized factors. Design Longitudinal cohort study Participants Women Veterans aged ≥ 50 with at least one Veterans Health Administration (VHA) clinical encounter in FY2012–2013. Main Measures Long-term psychoactive medications (opioids, benzodiazepines, sedative-hypnotics, antidepressants, antipsychotics, and antiepileptics, prescribed for ≥ 90/180 days) and psychoactive polypharmacy (overlapping for ≥ 1 day) from VHA pharmacy records; suicide and unintended overdose death through December 31, 2018. Key Results In this national sample of 154,558 midlife and older women Veterans (mean age 63.4, SD 9.3 years), 130 died by suicide and 175 died from unintentional overdose over an average of 5.6 years. In fully adjusted models, long-term opioids (hazard ratio (HR) 2.01, 95% CI 1.21–3.35) and benzodiazepines (HR 2.99, 95% CI 1.82–4.91) were associated with death by suicide; opioids (HR 3.62, 95% CI 2.46–5.34), benzodiazepines (HR 2.77, 95% CI 1.73–4.42), sedative-hypnotics (HR 1.87, 95% CI 1.06–3.29), antidepressants (HR 1.47, 95% CI 1.03–2.12), antipsychotics (HR 1.81, 95% CI 1.02–3.22), and antiepileptics (HR 2.17, 95% CI 1.48–3.19) were associated with unintended overdose death. Women who were co-prescribed ≥ 3 psychoactive medications had over 2-fold increased risk of suicide (HR 2.83, 95% CI 1.65–4.84) and unintended overdose death (HR 2.60, 95% CI 1.72–3.94). Conclusions Long-term psychoactive medications and psychoactive medication polypharmacy were important indicators of risk for death by suicide and death by unintended overdose among midlife and older women Veterans, even after accounting for psychiatric and substance use disorders.
Article
A pilot study examined the efficacy of the Gatekeeper Training Program designed for suicide prevention in Yogo teachers. The author explored the program’s effectiveness on Yogo teachers with over 20 and under 20 years of experience. Self-administered questionnaires were administered before and after the program to assess the teachers’ confidence in managing students, their willingness to act as gatekeepers, and their self-efficacy. Yogo teachers (N=51) participated in the study. The results indicated improvements in confidence, the willingness to act as gatekeepers, and self-efficacy, regardless of experience, suggesting the Gatekeeper Training Program’s efficacy. The results also showed that the program was more effective for teachers with over 20 years than under 20 years of experience, especially for early intervention items.
Article
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Purpose of Review As one of the leading causes of death worldwide, suicide has become an important public health concern. Several studies have evaluated key demographic factors such as age, gender, and race as increased risk factors for suicide. The goal of this review is to highlight elderly white males as a unique population at risk, as well as help shape future preventive efforts. Recent Findings Extensive literature review shows that many risk factors contribute to increased suicide rates in older white males. These may include the presence of mental illness, multiple medical conditions, family history, and occupation. In addition, there has been more evidence to suggest that social isolation and access to firearms as increasingly important suicide risk factors to consider, especially among older white males. Summary Increasing awareness of older white males as an at-risk group and focusing on minimizing social isolation and access to firearms may play significant roles in helping shape future preventative efforts relating to suicide.
Article
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We present a revision of the 1978 reformulated theory of helplessness and depression and call it the hopelessness theory of depression. Although the 1978 reformulation has generated a vast amount of empirical work on depression over the past 10 years and recently has been evaluated as a model of depression, we do not think that it presents a clearly articulated theory of depression. We build on the skeletal logic of the 1978 statement and (a) propose a hypothesized subtype of depression— hopelessness depression, (b) introduce hopelessness as a proximal sufficient cause of the symptoms of hopelessness depression, (c) deemphasize causal attributions because inferred negative consequences and inferred negative characteristics about the self are also postulated to contribute to the formation of hopelessness and, in turn, the symptoms of hopelessness depression, and (d) clarify the diathesis—stress and causal mediation components implied, but not explicitly articulated, in the 1978 statement. We report promising findings for the hopelessness theory and outline the aspects that still need to be tested. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
Background: General population survey data are presented on the lifetime prevalence of suicide attempts as well as transition probabilities to onset of ideation, plans among ideators, and attempts among ideators either with or without a plan. Risk factors for these transitions are also studied. Methods: Data are from part II of the National Comorbidity Survey, a nationally representative survey carried out from 1990 to 1992 in a sample of 5877 respondents aged 15 to 54 years to study prevalences and correlates of DSM-III-R disorders. Transitions are estimated using life-table analysis. Risk factors are examined using survival analysis. Results: Of the respondents, 13.5% reported lifetime ideation, 3.9% a plan, and 4.6% an attempt. Cumulative probabilities were 34% for the transition from ideation to a plan, 72% from a plan to an attempt, and 26% from ideation to an unplanned attempt. About 90% of unplanned and 60% of planned first attempts occurred within 1 year of the onset of ideation. All significant risk factors (female, previously married, age less than 25 years, in a recent cohort, poorly educated, and having 1 or more of the DSM-III-R disorders assessed in the survey) were more strongly related to ideation than to progression from ideation to a plan or an attempt. Conclusions: Prevention efforts should focus on planned attempts because of the rapid onset and unpredictability of unplanned attempts. More research is needed on the determinants of unplanned attempts.
Book
An ACT Approach Chapter 1. What is Acceptance and Commitment Therapy? Steven C. Hayes, Kirk D. Strosahl, Kara Bunting, Michael Twohig, and Kelly G. Wilson Chapter 2. An ACT Primer: Core Therapy Processes, Intervention Strategies, and Therapist Competencies. Kirk D. Strosahl, Steven C. Hayes, Kelly G. Wilson and Elizabeth V. Gifford Chapter 3. ACT Case Formulation. Steven C. Hayes, Kirk D. Strosahl, Jayson Luoma, Alethea A. Smith, and Kelly G. Wilson ACT with Behavior Problems Chapter 4. ACT with Affective Disorders. Robert D. Zettle Chapter 5. ACT with Anxiety Disorders. Susan M. Orsillo, Lizabeth Roemer, Jennifer Block-Lerner, Chad LeJeune, and James D. Herbert Chapter 6. ACT with Posttraumatic Stress Disorder. Alethea A. Smith and Victoria M. Follette Chapter 7. ACT for Substance Abuse and Dependence. Kelly G. Wilson and Michelle R. Byrd Chapter 8. ACT with the Seriously Mentally Ill. Patricia Bach Chapter 9. ACT with the Multi-Problem Patient. Kirk D. Strosahl ACT with Special Populations, Settings, and Methods Chapter 10. ACT with Children, Adolescents, and their Parents. Amy R. Murrell, Lisa W. Coyne, & Kelly G. Wilson Chapter 11. ACT for Stress. Frank Bond. Chapter 12. ACT in Medical Settings. Patricia Robinson, Jennifer Gregg, JoAnne Dahl, & Tobias Lundgren Chapter 13. ACT with Chronic Pain Patients. Patricia Robinson, Rikard K. Wicksell, Gunnar L. Olsson Chapter 14. ACT in Group Format. Robyn D. Walser and Jacqueline Pistorello
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This paper reports the results of a study which investigated the experiences of 75 people with chronic non-malignant pain People with chronic non-malignant pain can find that traditional medical techniques do not help their pain, and they have to learn to live with it However, pain can affect their lives in many ways Within this study, qualitative data were collected to illustrate what it meant to people to experience this chronic pain It was found that pain adversely affected many dimensions of sufferers' lives, and the effects extended to family and friends It seemed that having others believe the pain was crucial to many patients Health care professionals can offer these patients much in helping them come to terms with the way in which pain has affected both themselves and their lives
Article
Presents an animal model of how learned helplessness may manifest itself as depression and anxiety. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
Studied the relation of hopelessness to levels of depression and suicidal intent in 384 17-63 yr old suicide attempters using the Beck Depression Inventory and the Beck Helplessness Scale. Results support previous reports that hopelessness is the key variable linking depression to suicidal behavior. This finding has direct implications for the therapy of suicidal individuals. By focusing on reducing the sources of a patient's hopelessness, the professional may be able to alleviate suicidal crises more effectively than in the past. (30 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
The tendency to "catastrophize" during painful stimulation contributes to more intense pain experience and increased emotional distress. Catastrophizing has been broadly conceived as an exaggerated negative "mental set" brought to bear during painful experiences. Although findings have been consistent in showing a relation between catastrophizing and pain, research in this area has proceeded in the relative absence of a guiding theoretical framework. This article reviews the literature on the relation between catastrophizing and pain and examines the relative strengths and limitations of different theoretical models that could be advanced to account for the pattern of available findings. The article evaluates the explanatory power of a schema activation model, an appraisal model, an attention model, and a communal coping model of pain perception. It is suggested that catastrophizing might best be viewed from the perspective of hierarchical levels of analysis, where social factors and social goals may play a role in the development and maintenance of catastrophizing, whereas appraisal-related processes may point to the mechanisms that link catastrophizing to pain experience. Directions for future research are suggested.
Article
Objectives: Previous studies have shown that fibromyalgia [FMS] patients have certain personality characteristics. The objective of the present study was to examine a number of personality traits in these patients. Methods: Four groups of female patients participated in the study, 51 FMS patients, 51 rheumatoid arthritis patients, 50 lower back patients and 50 healthy women. The participants were administered a battery of self-report paper-and-pencil instruments measuring coping styles, state and trait anger, suicide risk, and social support. Results: The results showed that the personality traits studied here were similar between the three chronic pain patient groups. These patients scored significantly higher in the coping style of avoidance and on the measure of anger than the healthy women. Concerning the other variables no differences were observed. Specifically, the FMS group did not differ significantly from the other patient groups on any of the variables. Conclusions: The findings indicate that the specific personality traits studied here are not relevant for the FMS and other traits have to be examined.