Some Chronic-Pain Patients At Increased Suicide Risk

As any chronic-pain patient knows, it's easy to feel helpless when in pain, to be pessimistic about ever escaping it, and to find it difficult to keep pain out of your mind—in short, to “catastrophize” it.

In addition to being a poor strategy for coping with pain, catastrophizing has a potentially lethal downside: it can spark suicidal thoughts, a new investigation suggests. The inquiry was headed by Robert Edwards, Ph.D., an assistant professor of psychiatry at Johns Hopkins University. Results are in press with the journal Pain.

Edwards and his coworkers assessed 1,512 chronic-pain subjects to gauge their psychosocial functioning and to determine how much pain they experienced, how they coped with it, and whether they thought about committing suicide. The investigators then looked for associations between various factors and subjects' suicidal thoughts.

Almost a third of the subjects reported some form of recent suicidal ideation. To the researchers' surprise, there was only a modest link between suicidal thoughts and pain severity or duration. However, suicidal thoughts were strongly linked to depression and catastrophizing. Moreover, even when subjects' depression was taken into consideration, the link between suicidal thoughts and catastrophizing remained potent.

“These are the first findings to suggest a unique (for example, independent of pain severity or depressive–symptomatology) association between pain-coping strategies and suicide-related cognitions in the context of chronic pain,” Edwards and his group concluded in their study report.

“This study addresses a problem of tremendous public health importance—suicide in chronic-pain patients,” Jordan Karp, M.D., a University of Pittsburgh investigator with a special interest in pain and emotions, told Psychiatric News. “It appears that those patients who have symptoms of depression and are catastrophizers... are at greatest risk of having suicidal ideation. [Thus] it's our duty as clinicians to, one, treat the comorbid depression, and, two, provide or refer the patients for psychotherapy that specifically addresses these cognitive distortions to reduce their risk of suicide.”

In fact, in a previous inquiry Edwards and his team found that cognitive-behavioral therapy (CBT) can reduce catastrophizing in chronic-pain patients. The researchers will now explore not only whether CBT can reduce catastrophizing in these patients, but also whether such a reduction might reduce the frequency of suicidal thoughts, Edwards told Psychiatric News.

Still another question Edwards and his group is interested in answering, he said, is whether any medications can counter catastrophizing in chronic-pain patients, and if so, whether a medication-induced reduction in catastrophizing would in turn reduce the frequency of suicidal ideas.

For instance, a relatively new class of antidepressants—the combined selective serotonin-norepinephrine reuptake inhibitors (SNRIs)—have been found to combat depression and various kinds of pain as the tricyclic antidepressants do, but without the latter's side effects (Psychiatric News, March 3). Thus, it is possible that the SNRIs might be able to counter catastrophizing and suicidal ideas as well, Edwards hypothesized. He and his team have already found that the tricyclics are not effective in countering catastrophizing and pain in neuropathic pain subjects.

The study was funded by the National Institutes of Health.

An abstract of “Pain-Related Catastrophizing as a Risk Factor for Suicidal Ideation in Chronic Pain” can be accessed at<www.sciencedirect.com> by clicking on “P,” then “Pain.” ▪