Psychiatric–Medical ComorbidityPain and suicidal thoughts, plans and attempts in the United States☆
Introduction
Chronic pain is common in the United States, with over a quarter of adults reporting some form of persistent and/or significant pain [1], [2]. Pain is also associated with numerous general medical conditions and poorer mental health [3], [4], [5], [6]. Individuals with chronic pain have a higher prevalence of depression, anxiety, alcohol and drug abuse or dependence than those without pain [4], [7], [8], [9], [10].
Prior research has identified a link between pain and suicide. In a recent review, Tang and Crane [11] reported that chronic pain was associated with increased risk of suicide mortality (e.g., Refs. [12], [13]) and that rates of suicidal ideation and attempts were higher in individuals with pain than those without [14], [15]. Edwards et al. [16] found that over 30% of patients seeking treatment for chronic pain reported some form of recent suicidal ideation. Similarly, over 37% of patients receiving opioid therapy from their primary care physicians reported suicidal thoughts and over 20% reported a lifetime suicide attempt [17].
Of the existing research on pain and suicidality, few studies have utilized large, nonclinical samples. Magni et al. [18] examined data collected from a nationally representative sample of Hispanics in the early 1980s. In Hispanics, lifetime suicidal thoughts and attempts were approximately two to three times more common in those with abdominal pain than those without [18]. Additionally, Breslau et al. [19] examined a random sample of young adults in a large health care organization and found that migraine headaches were significantly associated with lifetime reports of suicide attempts after accounting for co-occurring psychiatric problems.
This line of research was substantially enhanced by a recent survey that examined the association between four chronic pain conditions (migraines, back pain, arthritis or fibromyalgia) and suicidal thoughts and attempts in population-based sample of Canadians [9]. These authors found that, even after controlling for psychiatric comorbidity, the presence of any pain condition was associated with increased risk of suicidal thoughts and attempts; this relationship was particularly strong for migraines and back pain. However, these analyses did not control for other common co-occurring medical conditions so the specific impact of pain, as opposed to medical disability, on suicidality remains unknown. Also, the analyses did not examine impact of pain conditions other than migraines, back pain, arthritis or fibromyalgia, although other types of pain are common and may also be problematic. Additionally, this effort did not examine the impact of multiple pain complaints on suicidal ideation, although patients who report one type of pain often have additional pain complaints [9], [10]. Further research is needed to replicate these findings and establish the relationship between differing types of pain and suicidality in representative samples of the general US population after controlling for other co-occurring psychiatric and medical conditions.
We examined the association between four measures of pain (back and neck, headache, other/unspecified nonarthritic pain and a summary count of these pain conditions) in the past 12 months and 12-month suicidal thoughts, plans and attempts in a nationally representative sample of US adults. We hypothesized that individuals with these two specific types of pain and those with other/unspecified nonarthritic pain would report greater likelihood of suicidal thoughts, plans and attempts than those who did not report each of these conditions. Additionally, we hypothesized that patients with multiple pain conditions would have greater risk of suicidal thoughts, plans and attempts than patients reporting only one pain condition. Finally, we hypothesized that 12-month pain would be associated with greater 12-month suicidal thoughts, plans and attempts even after controlling for other known risk factors for suicidality such as psychiatric comorbidities, general medical health conditions and demographic characteristics.
Section snippets
Methods
The National Comorbidity Survey Replication (NCS-R) is a psychiatric epidemiology survey that was carried out between February 2001 and April 2003 using a multistage clustered area probability sample of the English-speaking US household population ages 18 and over [20]. The NCS-R instrument consists of two parts. Part I includes a core diagnostic assessment of DSM-IV mental disorders (n=9282). Part II, which included the questions about chronic pain, was administered to 5692 of the 9282 NCS-R
Results
Based on a dataset of 5692 adults representing the adult US population, the 12-month prevalence of chronic pain is 19.0% (95% CI: 17.4, 20.5) for back or neck pain, 12.7% (95% CI: 11.5, 14.0) for headache pain and 6.7% for other nonarthritic pain (95% CI: 5.8, 7.5). The prevalence of any of these conditions was 29.0% (95% CI: 26.8, 31.2). These conditions were consistently related to suicidality. Headache had the strongest bivariate association with suicidality. Individuals suffering from
Discussion
According to the present findings, approximately 29% of the US population reports experiencing significant pain within the past 12 months. In unadjusted analyses, the presence of pain is significantly associated with an increased risk of suicidal ideation, planning and attempts. Even after accounting for other physical problems and psychopathology within the past 12 months known to increase suicide risk (e.g., depression, drug or alcohol use disorders), in most cases, those with pain remain at
Acknowledgment
We would like to thank the members of the NCS-R research group for allowing other researchers to access their data. A complete list of other NCS-R publications and the measures used in the NCS-R is available at http://www.hcp.med.harvard.edu/ncs. This manuscript has not been reviewed or endorsed by the NCS-R research group and does not necessarily represent the opinions of its members, who are not responsible for the contents.
References (27)
- et al.
Assessment of pain: a community-based diary survey in the USA
Lancet
(2008) - et al.
Is low back pain part of a general health pattern or is it a separate and distinctive entity? A critical literature review of comorbidity with low back pain
J Manipulative Physiol Ther
(2003) - et al.
Chronic back pain and major depression in the general Canadian population
Pain
(2004) - et al.
Chronic spinal pain and physical-mental comorbidity in the United States: results from the National Comorbidity Survey Replication
Pain
(2005) - et al.
Effects of pain duration on psychosocial adjustment in orthopedic patients: the importance of early diagnosis and treatment of pain
J Pain Symptom Manage
(1994) - et al.
Pain-related catastrophizing as a risk factor for suicidal ideation in chronic pain
Pain
(2006) - et al.
Addiction Severity Index in a chronic pain sample receiving opioid therapy
Journal of Substance Abuse Treatment
(2007) - et al.
Suicidality in chronic abdominal pain: an analysis of the Hispanic Health and Nutrition Examination Survey (HHANES)
Pain
(1998) - et al.
Migraine, psychiatric disorders, and suicide attempts: an epidemiologic study of young adults
Psychiatry Res
(1991) Health, United States
(2006)
Comorbid subjective health complaints in low back pain
Spine
Chronic pain and psychopathology: research findings and theoretical considerations
Psychosom Med
Psychological factors in chronic pain: evolution and revolution
J Consult Clin Psychol
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This work was supported by the Department of Veterans Affairs (VA) Health Services Research and Development Service (HSR&D) grants MRP 05-137 and IIR 04-104-2 and by the National Institute of Mental Health (NIMH) grant R01-MH078698-01. The views expressed in this report are those of the author and do not necessarily represent those of the VA or NIMH. We have no financial or other interests that might lead to a conflict of interest.