People who endure chronic migraines or back pain are more likely to attempt suicide, whether or not they also suffer from depression or another psychiatric condition, according to a new study.
"Clinicians who are seeing patients with certain pain conditions should be aware they are at increased risk of suicide," said study co-author Mark Ilgen, of the Veterans Affairs Serious Mental Illness Treatment Resource and Evaluation Center in Ann Arbor, Mich.
"Although undoubtedly psychiatric factors are important, there might be aspects of the pain that in and of themselves increase a person's risk," Ilgen said. "There might be something about someone with significant pain that puts them at increased risk."
The wide-ranging study, published online in the journal JAMA Psychiatry, involved more than 4.8 million people who received care from the US Veterans Health Administration during fiscal year 2005. Researchers identified those suffering from chronic pain and tracked them for the next three years to see if any died from suicide.
Suicide the 10th most common cause of death
The research team then looked for associations between suicide death - the 10th most common cause of death in the United States - and clinical diagnoses of chronic pain conditions, such as arthritis, back pain, migraines, neuropathy, headaches or tension headaches, fibromyalgia and psychogenic pain.
They found that all pain conditions except arthritis and neuropathy were associated with elevated suicide risk. But when they took into account the mental-health problems that chronic pain patients also had, the associations reduced for all but three types of chronic pain: back pain, migraines and psychogenic pain, which stems from psychological factors.
Dr Elspeth Cameron Ritchie, a retired Army colonel and psychiatrist living in Washington, DC, said the study clearly reinforces the anecdotal link between pain and suicide.
"It makes sense that pain is a risk factor for suicide," she said. "Often, suicide has several different things going on, but pain can be the straw that breaks the camel's back in terms of a person's decision not to go on."
Therapists performing a suicide-risk evaluation should consider adding a question regarding pain to the standard questions aimed at suicidal thoughts and planning, she said.
"It's not a standard question: 'Are you in pain?'" Ritchie said. "I would ask, 'Are you in pain?,' or 'Is pain an issue for you?'"
Pain increased people's risk of suicide
Psychogenic pain increased people's risk of suicide the most, followed by migraines and back pain. Psychogenic pain is chronic pain caused or exacerbated by mental or emotional problems, and Ilgen said it is a rare and not well understood condition.
"We think that's not so much about psychogenic pain per se, but the fact that the pain itself is poorly understood and may be poorly managed," Ilgen said. "There's not a clear treatment plan for that type of pain. It's likely that patients with this type of pain may be frustrated with their care and more hopeless and more at risk for suicide."
Hopelessness also could play a part in the elevated risk of suicide for migraine and chronic back pain sufferers - two common problems in the United States. Back pain, for instance, is the second most common pain complaint among Veterans Health Administration patients, behind only arthritis.
"Patients with these pain conditions also may be more likely to feel hopeless and to have impairments in occupational or social functioning that could lead more directly to suicidal thoughts and behaviors," according to the study.
"Negative expectations about one's ability to effectively manage or treat pain could lead to suicidal ideation, and these effects might be greatest for certain conditions, such as psychogenic pain, that do not have clear or effective treatments and may be stigmatized," the researchers said.
Disability also could be a factor in the increased suicide risk, particularly for people with back pain who used to be healthy and active, Ritchie said.
Ilgen said it is not known whether there are unique warning signs of suicide for chronic pain patients. He urged family and friends of patients to keep a close eye out for standard warning signs, such as intense depression, expressions of hopelessness, statements about suicidal thoughts or plans, or any indication that the person is not oriented toward the future.
"My best recommendation is to encourage the patient to reach out for professional help," Ilgen said. "Ask about their suicidal thoughts. Don't just skirt the issue; directly ask."
The US National Institute of Mental Health has more about suicide prevention.
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