Patient predictor variables for six forms of suicidality

The association of pain screening and pain level with suicide among US veterans with comorbid musculoskeletal and bipolar disorder diagnoses

BACKGROUND

High suicide rates are documented among persons with bipolar disorder diagnoses and pain diagnoses, but few studies have examined the association of pain with suicide mortality in individuals with comorbid pain and bipolar disorders. This study assessed the association of pain screening and pain severity with suicide mortality among veterans with comorbid bipolar and musculoskeletal disorder (MSD) diagnoses.

METHODS

A retrospective cohort study was conducted on 168,021 patients within the Veterans Health Administration (VHA) who received an MSD diagnosis from 2000 to 2015 and had a bipolar disorder diagnosis. Pain severity, comorbidities, demographics, and suicide mortality were extracted from VHA databases. Poisson regression examined relative risk of suicide by the presence pain screening and pain severity ratings.

RESULTS

Pain was assessed in 72.73 % of veterans. Suicide risk was greater in those not assessed (0.98 % versus 0.77 % in assessed group). However, this result did not persist after adjusting for covariates (RR = 1.06). Among those assessed, higher suicide risk was associated with moderate (RR = 1.10), severe pain (RR = 1.06), and no pain (reference) relative to mild pain (RR = 0.99). Major depression, substance use disorders, and prescribed opioids and benzodiazepines increased risk.

LIMITATIONS

Data were obtained from medical records; diagnoses were not confirmed via formal assessment, and no information was available on actual medication use or purpose. Over 25 % of the sample were missing pain severity ratings, which could have affected results.

CONCLUSIONS

Suicide risk factors among persons with bipolar disorder are complex and multifactorial. Providers should prioritize suicide prevention efforts following new onset or worsening pain.

Predictive Modeling for Suicide-Related Outcomes and Risk Factors among Patients with Pain Conditions: A Systematic Review

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.

Chronic pain and suicide risk: A comprehensive review

Death by suicide is one of the leading causes of mortality worldwide. Because individuals with chronic pain are at least twice as likely to report suicidal behaviors or to complete suicide, it is of utmost importance to target which risk factors contribute the most to increasing suicidality. This comprehensive review aims to provide an update on research advancements relating to the identification of potential risk factors for suicidality in individuals with chronic pain. Supporting the results of prior reviews, we found robust evidence that chronic pain itself, regardless of type, was an important independent risk factor for suicidality. The only sociodemographic factor found to be associated with suicidality in individuals with chronic pain was being unemployed/disabled. Depressive symptoms, anger problems, harmful habits (e.g. smoking, alcohol misuse, illicit drugs), childhood or adulthood adversities, and family history of depression/suicide were all also identified as general risk factors. Regarding pain-related factors, sleep problems, poorer perceived mental health, concurrent chronic pain conditions, and more frequent episodes of intermittent pain, were all found to be predictors of suicidality. Unexpectedly, pain characteristics (e.g. type, duration, and intensity/severity) and physical status (e.g. pain interference or disability) were not related to suicide risk. We also identified promising new psychosocial factors (e.g. mental defeat, pain catastrophizing, hopelessness, perceived burdensomeness and thwarted belongingness) associated with suicidality outcomes. A large number of these factors are amenable to change through targeted intervention, highlighting the importance of comprehensively assessing chronic pain patients at risk for suicide, while also incorporating a suicide prevention component into chronic pain management programs.

The Perception of Being a Burden in Acute and Chronic Pain Patients Is Associated with Affirmation of Different Types of Suicidality

OBJECTIVES

The perception of being a burden or self-perceived burden (SPB) is associated with suicide ideation in chronic pain patients (CPPs). The objective of this study was to determine if SPB is associated with five types of suicidality (wish to die, active suicide ideation, presence of suicide plan, history of suicide attempts, and preference for death over being disabled) in CPPs and acute pain patients (APPs).

METHODS

Affirmation of SPB was statistically compared between community nonpatients without pain (CNPWP), APPs, and CPPs. APPs and CPPs who had affirmed any of the five types of suicidality were compared statistically for affirmation of SPB. Hierarchical regression analysis was utilized to determine the significance of SPB in predicting each of the five types of suicidality in APPs and CPPs controlling for age, gender, race, education status, and two types of measures of depression (current depression and vegetative depression).

RESULTS

APPs and CPPs were statistically more likely to affirm SPB than CNPWPs and CPPs were more likely than APPs to do so. There were no differences between APPs and CPPs in affirming SPB in APPs and CPPs who had affirmed any of the five types of suicidality. In CPPs, SPB predicted each type of suicidality in a significant fashion utilizing both types of depression measures. For APPs, SPB predicted each type of suicidality in a significant fashion except for history of suicide attempt controlling for vegetative depression.

CONCLUSIONS

SPB is associated with the vast majority of different types of suicidality in APPs and CPPs.

The Psychological Evaluation of Patients with Chronic Pain: a Review of BHI 2 Clinical and Forensic Interpretive Considerations

Pain is the most common reason why patients see a physician. Within the USA, it has been estimated that at least 116 million US adults suffer from chronic pain, with an estimated annual national economic cost of $560-635 billion. While pain is in part a sensory process, like sight, touch, or smell, pain is also in part an emotional experience, like depression, anxiety, or anger. Thus, chronic pain is arguably the quintessential biopsychosocial condition. Due to the overwhelming evidence of the biopsychosocial nature of pain and the value of psychological assessments, the majority of chronic pain guidelines recommend a psychological evaluation as an integral part of the diagnostic workup. One biopsychosocial inventory designed for the assessment of patients with chronic pain is the Battery for Health Improvement 2 (BHI 2). The BHI 2 is a standardized psychometric measure, with three validity measures, 16 clinical scales, and a multidimensional assessment of pain. This article will review how the BHI 2 was developed, BHI 2 concepts, validation research, and an overview of the description and interpretation of its scales. Like all measures, the BHI 2 has strengths and weaknesses of which the forensic psychologist should be aware, and particular purposes for which it is best suited. Guided by that knowledge, the BHI 2 can play a useful role in the forensic psychologist's toolbox.

The pain suicidality association: a narrative review

OBJECTIVES

The objective of this narrative review was to examine recent evidence and, when necessary, past evidence on the association between pain and suicidality.

DESIGN

Fifty-eight research reports were found on this topic, which had not previously been reviewed. These reports were divided into groups by whether they addressed suicide ideation (SI), suicide attempts (SAs), or suicide completion (SC), and what population they represented (acute pain patients [APPs], chronic pain patients [CPPs], other than APPs/CPPs) and whether they controlled for relevant confounders. Information as to whether the results of these studies supported/did not support the association of pain and suicidality was abstracted. For each group of studies (above), a vote counting method was utilized to determine the overall percentage of studies supporting/not supporting the association of pain and suicidality. According to this percentage, the consistency of the data supporting this association was rated according to Agency for Healthcare Research and Quality guidelines.

RESULTS

The following groups of studies received an A consistency rating (consistent evidence from multiple studies): SI, SA, and SC for other than APPs/CPPs; and SI, SA, and SC for CPP prevalence greater than an appropriate control group. Also, a subgroup of the SI, SA, and SC studies for other than APPs/CPPs had controlled for behavioral issues (potential confounders). These three subgroups also received an A consistency rating. The 58 studies also identified a number of new predictor variables for SI, SA, and SC in CPPs.

CONCLUSIONS

These studies solidify the evidence for an association between pain and SI, SA, and SC in both CPPs and other than APPs/CPPs.