Examining the Relationship Between Pain Catastrophizing and Suicide Risk in Patients with Rheumatic Disease: the Mediating Role of Depression, Perceived Social Support, and Perceived Burdensomeness

Pain catastrophizing in rheumatic diseases: prevalence, origin, and implications

Pain is a crucial factor in rheumatic disorders, and reducing it is a primary goal of successful treatment. Adaptive pain-coping strategies can enhance this improvement, but maladaptive approaches such as pain catastrophizing may worsen overall patient well-being. This narrative review aims to provide a concise overview of the existing knowledge on pain catastrophizing in the most prevalent specific rheumatic disorders. The objective of this study was to improve understanding of this phenomenon and its implications, as well as to pinpoint potential directions for future research. We conducted searches in the MEDLINE/PubMed, SCOPUS, and DOAJ bibliography databases to identify articles related to pain catastrophizing in rheumatoid arthritis, psoriatic arthritis, axial spondylarthritis, systemic sclerosis, systemic lupus erythematosus, Sjögren's syndrome, juvenile idiopathic arthritis, and osteoarthritis (non-surgical treatment). Data extraction was performed on November 1, 2023. The investigators screened the identified articles to determine their relevance and whether they met the inclusion criteria. Following a bibliography search, which was further expanded by screening of citations and references, we included 156 records in the current review. The full-text analysis centred on pain catastrophizing, encompassing its prevalence, pathogenesis, and impact. The review established the role of catastrophizing in amplifying pain and diminishing various aspects of general well-being. Also, potential treatment approaches were discussed and summarised across the examined disorders. Pain catastrophizing is as a significant factor in rheumatic disorders. Its impact warrants further exploration through prospective controlled trials to enhance global patient outcomes.

Pain Catastrophizing: How Far Have We Come

The perception of pain is strongly influenced by various social, emotional, and cognitive factors. A psychological variable which has consistently been shown to exert its influence on pain is a cognitive process referred to as pain catastrophizing. Numerous studies have found it to be a strong predictor of pain intensity and disability across different clinical populations. It signifies a maladaptive response to pain marked by an exaggerated negative assessment, magnification of symptoms related to pain, and, in general, a tendency to experience marked pain-related worry, as well as experiencing feelings of helplessness when it comes to dealing with pain. Pain catastrophizing has been correlated to many adverse pain-related outcomes, including poor treatment response, unsatisfactory quality of life, and high disability related to both acute and chronic pain. Furthermore, there has been consistent evidence in support of a correlation between pain catastrophizing and mental health disorders, such as anxiety and depression. In this review, we aim to provide a comprehensive overview of the current state of knowledge regarding pain catastrophizing, with special emphasis on its clinical significance, and emerging treatment modalities which target it.

Experiential Avoidance, Pain, and Suicide Risk in a National Sample of Gulf War Veterans

OBJECTIVE

Pain confers risk for suicidal thoughts and behaviors. Experiential avoidance (EA), which is relevant to both pain and suicide risk, has not been studied as a potential mechanism for this relationship. The present study tested the hypothesis that pain indirectly impacts suicide risk through EA in a national sample of Gulf War veterans.

METHODS

Participants included a stratified random sample of United States veterans (N = 1,012, 78% male) who had served in the Gulf War region between August 1990 and July 1991. Validated scales were used to quantify levels of pain, EA, and suicide risk.

RESULTS

Regression analyses indicated independent associations between pain, EA, and suicide risk; moreover, the association between pain and suicide risk was no longer significant once EA was included in model. Bootstrapping analyses confirmed that EA partially accounted for the cross-sectional association between pain and suicide risk, independent of common co-occurring problems, such as depression, PTSD, and alcohol use disorder symptoms.

CONCLUSIONS

EA could be a key modifiable risk factor to target in people experiencing pain.

The Multi-dimensional Assessment of Suicide Risk in Chronic illness-20 (MASC-20): Development and validation

BACKGROUND

We developed and tested the psychometric properties of the Multi-dimensional assessment of suicide risk in chronic illness-20 (MASC-20), which assess suicidal behavior (SB), and its associated distress in chronic physical illness (CPI).

METHODS

Items were developed by incorporating inputs from patient interviews, a review of existing instruments, and expert consultations. Pilot testing with 109 patients and field testing with 367 patients with renal, cardiovascular, and cerebrovascular diseases were conducted. We analyzed Time (T) 1 data to select items and T2 data to examine psychometric properties.

RESULTS

Forty preliminary items were selected through pilot testing; 20 were finalized from field testing. Optimal internal consistency (α = 0.94) and test-retest reliability (Intra class correlation coefficient = 0.92) of the MASC-20 supported reliability. Good fit of the four-factor model (physical distress, psychological distress, social distress, and SB) from exploratory structural equation modeling demonstrated factorial validity. Its correlations with MINI suicidality (r = 0.59) and the Schedule of Attitudes Toward Hastened Death-abbreviated scores (r = 0.62) indicated convergent validity. Higher MASC-20 scores in patients with clinical levels of depression and anxiety and low health status demonstrated known-group validity. The MASC-20 distress score predicted SB beyond known SB risk factors, supporting incremental validity. A cutoff score of 16 was optimal for identifying suicide risk. The area under the curve was within a moderately accurate range. The sum of sensitivity and specificity (1.66) indicated diagnostic utility.

LIMITATIONS

MASC-20's applicability to other patient populations and its sensitivity to change requires testing.

CONCLUSIONS

The MASC-20 appears to be a reliable and valid tool for assessing SB in CPI.

Factors that influence the impact of Chronic Non-Cancer Pain on daily life: A partial least squares modelling approach

BACKGROUND

Chronic Non-Cancer Pain is pain of more than three months' duration and is not associated with an oncological condition. There is ample literature that recognises that Chronic Non-Cancer Pain impacts numerous areas of the life of the person who suffers from it. This impact is difficult to determine and quantify because Chronic Pain is a subjective experience.

OBJECTIVE

The objective of this study was to test a recursive model of hypothesised factors that comprise the concept of Chronic Non-Cancer Pain Impact on daily life using Partial Least Squares-Structural Equation Modelling.

DESIGN

A cross-sectional study was carried out. The sample size was calculated using G*Power V.3.1.9.4 with five parameters (two-tailed, large effect size (f² = 0.35), power of 0.95, statistical significance of 95% (α = 0.05) and 36 predictors). The minimum number of subjects was considered to be 137.

METHODS

A recursive model was built based on data from a sample of 395 people over 18 years of age with Chronic Non-Cancer Pain. Data collection was conducted between January and March 2020 at Pain Units and Primary Healthcare Centres belonging to the Spanish Public Health System in the province of Seville (Spain). Analyses were based on Partial Least Squares-Structural Equation Modelling. The internal consistency, convergent validity and discriminant validity of the internal measurement model were assessed. For the external measurement model, global model adjustment and structural validity were assessed. The predictive capacity of the final model was also evaluated. All analyses were performed using SmartPLS version 3.3.2 in consistent mode.

RESULTS

Findings showed an adequate validity of the proposed model, which comprised nine factors: pain catastrophising, hopelessness due to pain, support network, proactivity, treatment compliance, self-care, mobility, resilience, and sleep. The internal validity of the model (Cronbach's alpha and rho_A > 0.70; Average Variance Extracted>0.50; standardised outer loadings>0.60; Heterotrait-Monotrait-Ratio < 0.85), goodness of fit (Standardised Root Mean Square Residuals<0.08; Geodesic and Euclidean distance p-value<0.05) and predictive power with out-of-sample values (Stone-Geisser test>0.5) were adequate. The hypothesised structure of the instrument has also been confirmed (path coefficients>0.3; R² > 0.1; f² > 0.2).

CONCLUSIONS

The results have shown an adequate internal consistency, convergent validity and discriminant validity of the model. Likewise, the model has shown an adequate goodness of fit, and the validity of its structure and the hypothesis have been confirmed. However, more research is needed in this regard as the possible interaction between the different factors evaluated in the model with the confounding or moderating variables that may exist.

Validating the interpersonal theory of suicide among older adultspre- and peri-COVID-19 pandemic

OBJECTIVES

Global suicide rates are highest among older adults, and especially older men, yet proximal predictors of suicidal ideation in older age remain poorly understood. This study tested the Interpersonal Theory of Suicide in older men and women by investigating whether perceived burdensomeness and thwarted belongingness and/or their interaction are proximal predictors of suicidal ideation before versus during the global COVID-19 pandemic.

METHODS

The sample (N = 208) included healthy community-dwelling older Australian persons surveyed face-to-face pre-pandemic (n = 102), or online peri-pandemic (n = 106). Depression, social interaction, social satisfaction, thwarted belongingness, and perceived burdensomeness were assessed as predictors of suicidal ideation.

RESULTS

Perceived burdensomeness was a more proximal predictor of suicidal ideation among older adults than depression or thwarted belongingness. Suicidal ideation and perceived burdensomeness were higher in men than women, but sex did not moderate the influence of perceived burdensomeness, thwarted belongingness or social satisfaction on suicidal desire. The interaction between perceived burdensomeness and thwarted belongingness predicted more additional variance in suicidal ideation in the older persons surveyed during the COVID-19 pandemic relative to those surveyed before the pandemic.

CONCLUSION

Suicidal ideation among older persons peri-pandemic is discussed, and recommendations are made for age-specific suicide prevention strategies.

Association between functional disability type and suicide-related outcomes among U.S. adults with disabilities in the National Survey on Drug Use and Health, 2015-2019

While research on suicidal behavior for people with disability (PWD) suggests they experience higher risk than people without disability, less is known about variations among individuals with different disability types. This nationally representative, cross-sectional study compared differences in suicide-related outcomes (ideation, planning, attempts) among PWD by functional disability type (hearing, vision, cognitive, mobility, complex activity) and number. Secondary analysis of adult PWD in the 2015-2019 National Survey on Drug Use and Health (unweighted N = 35,544; representing 47,723,378 PWD, weighted) was used to estimate relationships between suicide-related outcomes and disability type and number. Most respondents were female (55.9%), and 36.0% were aged ≥65 years. Adjusted odds ratios (AORs) from multivariable logistic regression indicated that suicidal ideation and suicide attempt, respectively, were significantly more likely among individuals with cognitive (AOR = 1.71, 95% CI = 1.24-2.35; AOR = 2.54, 95% CI = 1.31-4.91), complex activity (AOR = 1.96, 95% CI = 1.37-2.81; AOR = 2.67, 95% CI = 1.32-5.41), and ≥2 limitations (AOR = 2.02, 95% CI = 1.52-2.69; AOR = 3.46, 95% CI = 1.84-6.50) than hearing limitation. Also, relative to other disability types, suicide-related outcomes were significantly more likely among individuals with cognitive limitation and complex activity limitation (p < 0.001). Additionally, suicide-related outcomes elevated in likelihood as the number of limitations increased, with the largest associations among those with ≥5 limitations for suicidal ideation (AOR = 2.31, 95% CI = 1.46-3.66), suicide planning (AOR = 3.34, 95% CI = 1.97-5.68), and suicide attempt (AOR = 6.37, 95% CI = 3.76-10.79). Subgroup analyses showed that presence of cognitive limitation and multiple limitations differentiated between suicidal ideators and suicide attempters. Further research is needed to identify causes of these risks and develop suicide prevention efforts for these particularly vulnerable groups.

Association Between Disability and Suicide-Related Outcomes Among U.S. Adults

INTRODUCTION

Although research has analyzed the sociodemographic and socioeconomic risks for suicide, only recently has suicide risk for people with disabilities been examined. This study investigates the associations between disability and distinct suicide-related outcomes, including suicidal ideation, suicide planning, and suicide attempt.

METHODS

This nationally representative, cross-sectional study comprised secondary analyses of the 2015-2019 National Survey on Drug Use and Health conducted in 2020 (N=198,640, representing 229,556,289 U.S. adults). Disability status comprised the presence of any disability; hearing, vision, mobility, cognitive, complex activity, or ≥2 limitations; and 1, 2, 3, 4, or ≥5 limitations. Suicide-related outcomes in the past year included none, suicidal ideation only, suicide planning, and suicide attempt. Multivariable logistic regression was applied to estimate the AORs.

RESULTS

Overall, 19.8% reported any disability. Results showed that people with disabilities were significantly more likely than those without disabilities to report suicidal ideation (AOR=2.13, 95% CI=1.93, 2.36), suicide planning (AOR=2.66, 95% CI=2.27, 3.11), and suicide attempt (AOR=2.47, 95% CI=2.05, 2.98). Furthermore, individuals within each limitation count group were significantly more likely than people without disabilities to report suicide-related outcomes (p<0.001), with the largest magnitudes among those with ≥5 limitations for suicidal ideation (AOR=3.80, 95% CI=2.32, 6.23), suicide planning (AOR=6.45, 95% CI=3.52, 11.80), and suicide attempt (AOR=8.19, 95% CI=4.45, 15.07).

CONCLUSIONS

People with various types of functional disabilities had an elevated risk for suicide-related outcomes, compared with people without disabilities. The more limitations a person had progressively increased their risk. These findings call for focused attention to the mental health of people with disabilities, including suicide prevention efforts that accommodate their needs.

Usual presence and intensity of pain are differentially associated with suicidality across chronic pain conditions: A population-based study

OBJECTIVES

This study examined the prevalence of suicidality and associations with pain characteristics (i.e., presence of usual pain/discomfort, pain intensity) among those with chronic pain conditions (i.e., arthritis, migraine, back pain).

METHODS

We analyzed data from the 2012 Canadian Community Health Survey-Mental Health supplement (N = 25,113), including self-reported pain characteristics and suicidality. Weighted cross-tabulations described suicidality prevalence estimates according to pain characteristics among each chronic pain condition. Multiple logistic regressions evaluated associations between the presence of usual pain/discomfort and suicidality across pain conditions. Post-hoc analyses examined pain intensity in significant associations.

RESULTS

Across pain conditions, rates of suicidality were greater in those usually in pain and with more severe pain, compared to mild or moderate pain. After adjustment, usual pain/discomfort was associated with increased odds of suicide ideation (AOR = 1.79, 95% CI [1.19-2.68], p < .05) and attempts (AOR = 2.49, 95% CI [1.25-4.98], p < .05) among those with migraines, and plans (AOR = 1.55, 95% CI [1.04-2.31], p < .05) in those with back pain (reference = absence of usual pain). Usual pain/discomfort was not associated with suicidality in those with arthritis after adjusting for sociodemographics and psychiatric comorbidity. Post-hoc analyses showed that severe pain was associated with elevated odds of suicide ideation (AOR = 2.19, 95% CI [1.07-4.48], p < .05) in migraines and plans (AOR = 3.11, 95% CI [1.42-6.80], p < .01) in back pain (reference = mild pain).

CONCLUSION

Our findings may facilitate a more targeted approach to screening for suicidality among chronic pain populations.

Activity Patterns and Functioning. A Contextual-Functional Approach to Pain Catastrophizing in Women with Fibromyalgia

Background: The psychological flexibility model states that activity patterns are not deemed to be intrinsically functional or dysfunctional; it is considered that underlying factors, such as personal goals and contextual factors, are what will determine their effects on disability. Pain catastrophizing has frequently been associated with several important pain-related outcomes. Despite its recent conceptualization within affective–motivational approaches, its moderating role between activity patterns and dysfunction has not been analyzed. Methods: This study analyzes the moderating role of pain catastrophizing and its dimensions (Pain Catastrophizing Scale) between activity patterns (Activity Patterns Scale) and disease impact (Fibromyalgia Impact Questionnaire—Revised) in 491 women with fibromyalgia. Results: Activity avoidance (p < 0.001), excessive persistence (p < 0.001) and pacing (p < 0.01) patterns were positively associated with fibromyalgia impact. Helplessness shows a moderating role between pain avoidance (B = 0.100, t =2.30, p = 0.021, [0.01, 0.18]), excessive persistence (B = −0.09, t = −2.24, p = 0.02, [−0.18, −0.01]), pain persistence (B = −0.10, t = −2.04, p = 0.04, [−0.19, −0.004]) and functioning. Conclusion: Helplessness (within pain catastrophizing) is a relevant variable within psychological flexibility models applied to activity patterns. Specifically, pain avoidance is especially dysfunctional in patients with high helplessness. To improve excessive persistence and pain persistence, it is necessary to reduce helplessness before regulating activity patterns.

Beyond Rheumatoid Arthritis Evaluation: What are We Missing?

Rheumatoid Arthritis (RA) is a chronic inflammatory autoimmune systemic disease that preferentially affects small and large joints with a progressive course and can become deforming and disabling. In recent years, much progress has been made in the evaluation of inflammation and disease activity, however, there are other factors that have a high impact on the quality of life of these patients, such as depression, anxiety, fatigue, sleep disorders, suicidal behavior, fibromyalgia, sexual activity, sarcopenia, frailty, cachexia and obesity that are not always evaluated by rheumatologists. This review shows that the evaluation and timely detection of these aspects in patients with RA could interfere with the prognosis and improve their quality of life.

The Mediating Role of Depressive Symptoms, Hopelessness, and Perceived Burden on the Association Between Pain Intensity and Late-Life Suicide in Rural China: A Case-Control Psychological Autopsy Study

Background: Few studies have investigated the roles of psychosocial factors such as depressive symptoms and hopelessness on the relationship between pain and suicide with inconsistent results. The study aimed to analyze the impact of pain intensity on suicide death and to estimate the degree to which depressive symptoms, hopelessness, and perceived burden may explain the association in Chinese rural elderly. Methods: Using a 1:1 matched case-control design, we collected data from 242 elderly suicide cases and 242 living community controls by psychological autopsy method in rural China, including sociodemographic characteristics, pain intensity, depression, hopelessness, perceived burden, physical diseases, and social support. Conditional logistic regression was employed to assess the association between pain intensity and completed suicide. Mediation analysis using the KHB method was applied to explore the mediation effects from depressive symptoms, hopelessness, and perceived burden. Results: The result of multivariable logistic regression showed that unemployment [odds ratio (OR) = 5.06, 95% confidence interval (CI): 1.76-14.49], higher levels of hopelessness (OR = 7.72, 95% CI: 3.49-17.10), depressive symptom (OR = 15.82, 95% CI: 4.53-55.25), and severe pain (OR = 3.46, 95% CI: 1.31-9.13) were significantly associated with elevated suicide risk in older adults in rural China. Depressive symptoms, hopelessness, and perceived burden significantly mediated 43.71% of the pain-suicide association (p = 0.020), with 17.39% due to depressive symptoms, 17.63% due to hopelessness, and 8.69% due to perceived burden. Conclusions: Regular screening of pain, depressive symptoms, hopelessness, and perceived burden using simple but sensitive questions or scales for older adults with pain is vital for the prevention and early detection of suicide risk in Chinese rural areas. Moreover, the importance of pain management and psychological interventions targeted on depressive symptoms and hopelessness should be emphasized.

The Effect of Pain Catastrophizing on Depression among Older Korean Adults with Chronic Pain: The Mediating Role of Chronic Pain Interference and Sleep Quality

Pain catastrophizing is a notable concept associated with change in chronic pain interference and depression. Sleep quality is also one of the important factors affecting geriatric depression. This study examined the mediating effects of chronic pain interference and sleep quality on the relationship between pain catastrophizing and depression. This study is a secondary data analysis that analyzed a total of 138 older Korean adults with chronic pain. The participants were selected from a single elderly daycare center in a city in South Korea. Also, the multiple regression analysis and PROCESS macro with bootstrapping were used. The results revealed that chronic pain interference and sleep quality mediated the relationship between pain catastrophizing and depression, respectively. Furthermore, chronic pain interference and sleep quality sequentially and dually mediated the effect of pain catastrophizing on depression. In the management of depression in the elderly, persistent complaints of pain should not be disregarded, irrespective of the intensity of their chronic pain. Psychological intervention is needed to alleviate negative thoughts about chronic pain and to increase the ability to cope with chronic pain. In addition, it is important to assess sleep patterns and to develop interventions to improve sleep quality, because depression in the elderly could appear as a symptom of a sleep problems.

Effect of pain on depression among nursing home residents: Serial mediation of perceived social support and self-rated health. A cross-sectional study

Aim

The aim of this study was to investigate how perceived social support and self‐rated health together could mediate the relationship between pain and depression among Chinese nursing home residents with pain.

Methods

The study was conducted in 38 nursing homes in 13 cities in China. A convenience sample of 2154 older adults responded to the questionnaire survey. A mediation analysis was performed on the data of 990 participants with pain. The data were collected by a questionnaire consisting of socio‐economic and demographic characteristics, the Geriatric Depression Scale‐15, the Multidimensional Scale of Perceived Social Support, Self‐rated Health Scale and the Numerical Rating Scale of pain. The sample was subdivided by sex. Descriptive analysis, t‐tests, chi‐squared tests, Mann–Whitney U‐tests, Spearman correlation analyses and the bootstrap method were used to analyze data.

Results

The prevalence rate of pain and depression among nursing home residents were 46.0% and 20.7% respectively. Pain, perceived social support and self‐rated health were all significantly correlated with depression (r = 0.217, P < 0.01; r = −0.216, P < 0.01; r = 0.385, P < 0.01, respectively). Perceived social support and self‐rated health independently and in series partly explained the relationship between pain and depression.

Conclusions

The results of the study showed that pain was associated with low perceived social support first, and then poor self‐rated health, which was in turn related to the development of depression among nursing home residents with pain. For nursing home residents, perceived social support and self‐rated health as an internal resource can affect the ability to overcome the suffering of pain and reduce the level of depression. Geriatr Gerontol Int 2020; 20: 1234–1240.

Pain as a risk factor for suicidal ideation. A population-based longitudinal cohort study

OBJECTIVE

To examine the longitudinal association between pain and suicidal ideation in the general adult population.

METHOD

Data were used from two waves (baseline and three-year follow-up) of the Netherlands Mental Health Survey and Incidence Study-2. Persons without prior 12-month suicidal ideation at baseline were included in this study (N = 5242). Pain severity and interference due to pain in the past month were measured using the 36-item Short Form Health Survey. Suicidal ideation and DSM-IV mental disorders were assessed using the Composite International Diagnostic Interview. Logistic regression analyses were performed.

RESULTS

Moderate to very severe pain (OR 3.39, p < .001) and moderate to very severe interference due to pain (OR 2.35, p .01) were associated with a higher risk for incident suicidal ideation at follow-up after adjustment for baseline sociodemographic variables and mental disorders. No interaction effects were found between pain severity or interference due to pain and mental disorders.

CONCLUSION

Moderate to severe pain and interference due to pain are risk factors for suicidal ideation independently of concomitant mental disorders. We suggest taking assessment and management of suicidal ideation in patients with pain into account both in clinical treatment as well as in suicide prevention action plans.

The Relationship Between Anxiety, Depression, Suicidal Ideation and Quality of Life in Patients with Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a chronic disease and many patients with RA experience lifelong anxiety and depression. The aim of this study is to provide an assessment of anxiety, depression, suicidal ideation, disease activity and quality of life in patients with RA. Fifty patients were included in the study. Hospital Anxiety and Depression Scale (HADS), Short Form Health Survey (SF-36), Beck Scale for Suicide Ideation (BSSI) and Disease Activity Score (DAS-28) were applied. A statistically negative correlation was found between HADS-A and HADS-D scores and all subscales of SF-36. There was a statistically negative correlation between the DAS-28 score and the subscales of the SF-36 except mental health and bodily pain. Suicidal ideation was associated with anxiety and depression and BSSI scores of patients suffering from anxiety and depression are higher than the patients not suffering from anxiety and depression. There was a statistically negative correlation between BSSI and the subscales of SF-36 excepting physical role. This study indicated that anxiety, depression, quality of life, disease activity and suicidal ideation are related to each other in patients with RA. The presence of concomitant anxiety and depression may lead to suicide and poor quality of life and may worsen the prognosis of the RA.

Pain catastrophizing as a predictor of suicidal ideation in chronic pain patients with an opiate prescription

Chronic pain and opioid use are associated with increased risk for suicidal ideation and behaviors (SIB) in cross-sectional studies, particularly among individuals who catastrophize about their pain. This study examined the longitudinal association between two styles of pain coping, catastrophizing and hoping/praying, as predictors of subsequent SIB, as well as possible mediators of this association among patients with chronic pain receiving long-term opioid therapy. Participants (n = 496) were adults with chronic nonmalignant pain on long-term opioid therapy who did not develop an opioid use disorder. Participants were assessed for pain coping, suicidal ideation, depression, social support and pain interference at baseline, and were reassessed for SI, depression, and pain interference at 6- and 12-month follow-ups. Catastrophizing was a significant predictor of increased subsequent SIB, whereas hoping/praying did not protect against future SIB. The relationship between catastrophizing and future SIB was mediated by depression, but not social support or pain interference. In conclusion, catastrophizing was an important predictor of subsequent SIB due to its effect on increasing depression among patients with chronic nonmalignant pain receiving long-term opioid therapy. Future research should explore the extent to which targeting catastrophizing reduces subsequent depression and suicide risk.

A Network Analysis of the Links Between Chronic Pain Symptoms and Affective Disorder Symptoms

BACKGROUND

A range of psychological constructs, including perceived pain, self-efficacy, and pain avoidance, have been proposed to account for the comorbidity of chronic pain and affective disorder symptoms. Despite the likely inter-relation among these constructs, few studies have explored these predictors simultaneously. As such, the relative contributions of these psychological influences remain an open question.

PURPOSE

The present study uses a novel, network model approach to help to identify the key psychological contributors to the pain-affective disorder link.

METHOD

A cross-sectional design was implemented. The sample comprised 169 individuals with chronic pain (M_age 49.82; range 22-80 years; 58% female) admitted to a metropolitan chronic pain clinic in Victoria, Australia. Participants completed self-report measures of anxiety, depressive, and pain symptoms, pain self-efficacy, fear avoidance beliefs, perceived control, and pain-related disability.

RESULTS

Network analysis identified self-efficacy, fear avoidance, and perceived disability as key constructs in the relationship between pain and affective disorder symptoms, albeit in different ways. While self-efficacy appeared to have direct links to other constructs in the network model, fear avoidance and perceived disability seemed to function more as mediators, linking other constructs in the model. Perceived control and anxiety were found to be less influential in the model.

CONCLUSIONS

Present findings identify self-efficacy, fear avoidance, and perceived disability as plausible candidate variables to target to disrupt the link between pain experience and affective disorder symptoms. However, further testing with longitudinal designs is needed to confirm this.

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.

Chronic Pain Among Suicide Decedents, 2003 to 2014: Findings From the National Violent Death Reporting System

Background

More than 25 million adults in the United States have chronic pain. Chronic pain has been associated with suicidality, but previous studies primarily examined nonfatal suicidal behaviors rather than suicide deaths associated with chronic pain or the characteristics of such deaths.

Objective

To estimate the prevalence of chronic pain among suicide decedents in a large multistate sample and to characterize suicide decedents with and without chronic pain.

Design

Retrospective analysis of National Violent Death Reporting System (NVDRS) data. The NVDRS links death certificate, coroner or medical examiner, and law enforcement data collected by investigators, who often interview informants who knew the decedent to gather information on precipitating circumstances surrounding the suicide. Information is abstracted by using standard coding guidance developed by the Centers for Disease Control and Prevention.

Setting

18 states participating in the NVDRS.

Participants

Suicide decedents with and without chronic pain who died during 1 January 2003 to 31 December 2014.

Measurements

Demographic characteristics, mechanism of death, toxicology results, precipitating circumstances (mental health, substance use, interpersonal problems, life stressors), and suicide planning and intent.

Results

Of 123 181 suicide decedents included in the study, 10 789 (8.8%) had evidence of chronic pain, and the percentage increased from 7.4% in 2003 to 10.2% in 2014. More than half (53.6%) of suicide decedents with chronic pain died of firearm-related injuries and 16.2% by opioid overdose.

Limitation

The results probably underrepresent the true percentage of suicide decedents who had chronic pain, given the nature of the data and how they were captured.

Conclusion

Chronic pain may be an important contributor to suicide. Access to quality, comprehensive pain care and adherence to clinical guidelines may help improve pain management and patient safety.

Primary Funding Source

None.

Differentiation of direct and indirect socioeconomic effects on suicide attempts in South Korea

Despite the wide recognition of the inverse association between socioeconomic position (SEP) and suicidal behaviors, its underlying process and potential mediators are little known. This study investigated the pathway from SEP to suicide attempts with attention to potential mediators.From the Korean Health and Nutrition Examination Survey 2007-2013, which is a nationwide cross-sectional survey of the health and nutritional status, a total of 34,565 participants (≥30 years) were included in the analysis. To unfold the pathways linking SEP to suicide attempts, the direct and indirect effects of 3 SEP measures (educational attainment, household income, and occupational group) and 3 mediators (physical illness, mental health problems, and problematic drinking) were differentiated using structured equation model (SEM).Most of direct and indirect effects of educational attainment, household income, and occupational group on suicide attempts were significant; Nonemployment status had the largest total (β = 0.291, P < .01) and direct effects (β = 0.212, P < .01), while educational attainment had the largest indirect effect (β = -0.124, P < .01). Educational attainment was mainly mediated by physical illness and problem drinking, whereas household income and occupational group were mainly mediated by anxious or depressed mood and problem drinking. Physical illness played a major role in explaining suicide attempts, compared to mental health problem and problem drinking.Overall, experience of socioeconomic disadvantage increased suicide attempts independently of mental and physical problems. An extension of suicide prevention program is required for comprehensively targeting people with general problems such as physical illness and low SEP, complemented to narrowly targeting high risk group with, such as mental health problem.