Suicidal thoughts and behavior among adults with self-reported pain conditions in the national comorbidity survey replication

What Predicts a Longer Period of Pain in Patients Referred to an Interdisciplinary Center for Pain Care?

Chronic musculoskeletal pain (CMP) is a global health condition that affects thousands of people. CMP can substantially affect the functional capacity and quality of life of the people impacted, resulting in high costs for health care and social security systems. Sociodemographic factors may play a significant role in pain chronification prevention and control programs. Thus, current risk factors for CMP must be seriously considered as part of an interdisciplinary management strategy. The purpose of the study was to identify the primary sociodemographic characteristics of CMP patients at a multidisciplinary and specialized center for chronic pain. This is a retrospective investigation based on a review of medical records. Age, gender, income, and the time of onset of pain symptoms were among the variables included in the analyzed data. To analyze variables related to the duration of discomfort, a multiple regression model was utilized. Sociodemographic factors explained 37.94% of experiencing prolonged pain, according to the study's findings. Being female and having a family income above the minimum wage were variables that were directly proportional to discomfort duration. Age was not associated with a prolonged duration of pain perception.

Medically unexplained pain and suicidal ideation among US adults

BACKGROUND

Chronic pain is an established risk factor for suicide. Pain syndromes are complex to diagnose, particularly in cases with limited evidence of injury or pathology. The goal of this study is to assess whether pain of unknown origin (i.e., medically-unexplained pain, MUEP) is more strongly associated with suicide behaviors than pain with a diagnostic explanation.

METHODS

Data comes from the National Comorbidity Survey-Replication, a nationally-representative sample of US adults. Analysis was limited to participants with a lifetime history of any type of chronic pain (n = 3421), which were categorized as having medically-explained pain (MEP, e.g., pain due to a specific health condition or resulting from an injury identified in an x-ray) or MUEP. Logistic regression, using survey procedures, was used to assess the relationship between lifetime MUEP and lifetime history of suicidal ideation and attempts.

RESULTS

Approximately 1 in 10 (11.6 %) adults with chronic pain had MUEP. Those with MUEP reported earlier age of pain onset and more impairment due to health problems. Suicidal ideation was reported by 18.7 % of those with MEP and 28.4 % of those with MUEP. In fully-adjusted models, MUEP was associated with 1.60 times (95 % CI: 1.17-2.18) higher odds of suicidal ideation, and 1.89 (1.25-2.83) higher odds of suicide attempt, compared to MEP.

LIMITATIONS

Cross-sectional analysis; MUEP assessed by self-report.

CONCLUSIONS

Among adults with chronic pain, those with MUEP are more likely to report suicide behaviors. Findings illustrate a role for diagnostic and treatment processes in the relationship between pain and suicide.

Association of chronic pain with suicide attempt and death by suicide: a two-sample Mendelian randomization

Prior studies have suggested an association between chronic pain and suicidal behavior. However, evidence supporting the causal nature of this association, and the role played by depression, remain difficult to establish due to confounding. We investigated associations of chronic pain with suicide attempt and death by suicide as well as the mediating role of depression in this association using a genetically informed method strengthening causal inference. We conducted a two-sample Mendelian randomization. Independent SNPs (N = 97) from the multisite chronic pain GWAS (NGWAS = 387,649) were used as instrumental variables to test associations of chronic pain with suicide attempt (measured from hospital records; NGWAS = 50,264) and death by suicide (measured from official death causes; NGWAS = 18,085). Indirect associations of chronic pain with suicide attempt and death by suicide via major depressive disorder (NGWAS = 173,005) were estimated. Primary analyses were supported by a range of sensitivity and outlier analyses. We found evidence supporting the contribution of chronic pain to increasing the risk of suicide attempt (OR = 1.67, CI = 1.21-2.35) and death by suicide (OR = 2.00, CI = 1.10-3.62). Associations were consistent across sensitivity analysis methods, and no evidence for outliers driving these associations was found. Through mediation analyses, we found that major depressive disorder explained a substantial proportion of the association between chronic pain and suicide attempt (proportion mediated = 39%; ORindirect association = 1.32, CI = 1.09-1.61) and death by suicide (proportion mediated = 34%; ORindirect association = 1.40, CI = 1.13-1.73). Our findings suggest that both pain management interventions and prevention of depression are likely to be effective strategies to reduce suicide risk in individuals with chronic pain.

The 8-Year Course of Acute Physical Pain Reported by Patients With Borderline Personality Disorder and Comparison Subjects With Other Personality Disorders

The present study examines the 8-year course of physical pain and its interference with functioning in patients with borderline personality disorder (BPD) and a comparison group of patients with other personality disorders (other-PD). Participants completed the Brief Pain Inventory (BPI) at five assessments, each separated by 2 years. Results showed that across all 13 domains assessed, participants with BPD reported significantly higher levels of acute physical pain and its functional interference than other-PD comparison subjects. The severity of physical pain and its interference with multiple domains of functioning were relatively stable over 8 years of assessment for both study groups. Within the BPD group, pain was significantly associated with older age, comorbid major depressive disorder (MDD), and history of a physically violent partner. Taken together, these results suggest that physical pain is a serious health issue for individuals with BPD that interferes with functioning across a wide spectrum of areas.

Mental Defeat and Suicidality in Chronic Pain: A Prospective Analysis

Living with chronic pain has been identified as a significant risk factor for suicide. Qualitative and cross-sectional studies have reported an association between mental defeat and suicidal thoughts and behavior in patients with chronic pain. In this prospective cohort study, we hypothesized that higher levels of mental defeat would be associated with increased suicide risk at a 6-month follow-up. A total of 524 patients with chronic pain completed online questionnaires measuring variables related to suicide risk, mental defeat, sociodemographic, psychological, pain, activity, and health variables. At 6 months, 70.8% (n = 371) of respondents completed the questionnaires again. Weighted univariate and multivariable regression models were run to predict suicide risk at 6 months. The clinical suicide risk cutoff was met by 38.55% of the participants at baseline and 36.66% at 6 months. Multivariable modeling revealed that mental defeat, depression, perceived stress, head pain, and active smoking status significantly increased the odds of reporting higher suicide risk, while older age reduced the odds. Receiver operating characteristic (ROC) analysis showed that assessment of mental defeat, perceived stress, and depression is effective in discriminating between 'low' and 'high' suicide risk. Awareness of the prospective links from mental defeat, depression, perceived stress, head pain, and active smoking status to increased suicide risk in patients with chronic pain may offer a novel avenue for assessment and preventative intervention. PERSPECTIVE: Results from this prospective cohort study suggest that mental defeat is a significant predictor of increased suicide risk among patients with chronic pain, along with depression, perceived stress, head pain, and active smoking status. These findings offer a novel avenue for assessment and preventative intervention before risk escalates.

Tension-Type Headache in Children and Adolescents

In pediatric neurology, tension-type headache (TTH) represents a very common type of primary headache during the pediatric age. Despite the high prevalence of TTH, this diagnosis is often underestimated in childhood, with relevant difficulties in the differential diagnosis of TTH from secondary and primary headache manifestations. Even among primary headaches, a clinical overlap is not so infrequent in children: migraine attacks could present tension headache-like features while tension-type headaches may display migraine-like symptoms as well. Several variables play a role in the complex trajectory of headache evolution, such as hormonal changes during adolescence, triggers and genetic and epigenetic factors. The trajectories and outcomes of juvenile migraine and TTH, as well as the transition of one form to the other, have been investigated in several long-term prospective studies. Thus, the aim of this paper is to review the current literature on the differential diagnosis workout of TTH in pediatrics, the possible outcomes during the developmental age and the appropriate therapeutic strategies. Indeed, TTH represents a challenging diagnostic entity in pediatrics, both from a clinical and a therapeutic point of view, in which early diagnosis and appropriate treatment are recommended.

The Use of Opioids in the Management of Chronic Pain: Synopsis of the 2022 Updated U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline

DESCRIPTION

In May 2022, leadership within the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) approved a joint clinical practice guideline for the use of opioids when managing chronic pain. This synopsis summarizes the recommendations that the authors believe are the most important to highlight.

METHODS

In December 2020, the VA/DoD Evidence-Based Practice Work Group assembled a team to update the 2017 VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain. The guideline development team included clinical stakeholders and conformed to the National Academy of Medicine's tenets for trustworthy clinical practice guidelines. The guideline team developed key questions to guide a systematic evidence review that was done by an independent third party and distilled 20 recommendations for care using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. The guideline team also created 3 one-page algorithms to help guide clinical decision making. This synopsis presents the recommendations and highlights selected recommendations on the basis of clinical relevance.

RECOMMENDATIONS

This guideline is intended for clinicians who may be considering opioid therapy to manage patients with chronic pain. This synopsis reviews updated recommendations for the initiation and continuation of opioid therapy; dose, duration, and taper of opioids; screening, assessment, and evaluation; and risk mitigation. New additions are highlighted, including recommendations about the use of buprenorphine instead of full agonist opioids; assessing for behavioral health conditions and factors associated with higher risk for harm, such as pain catastrophizing; and the use of pain and opioid education to reduce the risk for prolonged opioid use for postsurgical pain.

Risks of suicide in migraine, non-migraine headache, back, and neck pain: a systematic review and meta-analysis

Objective

To conduct a systematic review and meta-analysis on suicidal ideation, attempts, and death in patients with head, neck, and back pain.

Method

Search was performed using PubMed, Embase, and Web of Science from the date of the first available article through September 31, 2021. A random effects model was used to estimate the pooled odds ratios (ORs) and 95% confidence intervals (95% CI) for the association between suicidal ideation and/or attempt and head, back/neck pain conditions. Articles describing non-migraine headache disorders and death by suicide were also reviewed but not included in the meta-analysis due to an insufficient number of studies.

Results

A total of 20 studies met criteria for systemic review. A total of 186,123 migraine patients and 135,790 of neck/back pain patients from 11 studies were included in the meta-analysis. The meta-analysis showed that the estimated risk of combined suicidal ideation and attempt in migraine [OR 2.49; 95% CI: 2.15-2.89] is greater than that in back/neck pain pain [OR 2.00; 95% CI: 1.63-2.45] compared to non-pain control groups. Risk of suicide ideation/planning is 2 folds higher [OR: 2.03; 95% CI: 1.92-2.16] and risk of suicide attempt is more than 3 folds higher [OR: 3.47; 95% CI: 2.68-4.49] in migraine as compared to healthy controls.

Conclusion

There is an elevated risk of suicidal ideation and attempt in both migraine and neck/back pain patients in comparison to healthy controls, and this risk is particularly higher among migraine patients. This study underscores the critical need for suicide prevention in migraine patients.

Demoralization and Suicidal Ideation in Chronic Pain Patients

The literature has clearly stressed that patients suffering from chronic pain are at high risk of suicidal behavior (SB). Hence the need to improve the characterization of this behavior risk profile in these patients. Some findings indicate a possible relationship between demoralization and pain, with functional disability found to be correlated with demoralization. The primary objective of this study was to investigate the relationship between demoralization and suicidal ideation (SI) in patients with chronic pain. The secondary objective was to verify whether demoralization can occur independently of depression in these patients. Inclusion criteria were patients with chronic pain, with SI or not, matched for age and gender, aged > 18 years. Seventy patients with SI and 70 patients without SI were included. Between-group difference was statistically significant (F=1.064; t= 7.21, p<0.001, d=1.22), confirming the presence of numerous and intense depressive symptoms in the patients of the SI group. Regarding the Demoralization Scale (DS), the difference between the two groups was statistically highly significant (F=1.49; t=9.44; p<0.001, d=1.6). There was also a strong positive correlation between DS and Beck Depression Inventory (BDI-II) (R=0.749; p<0.001 for the study group and R=0.704; p<0.001 for the control group). Furthermore, there was a strong positive correlation between the DS and the Scale for Suicide Ideation (SSI) in the SI patients group, meaning that high demoralization is associated with higher suicidal ideation as well. Our findings did not allow us to distinguish between the notions of depression and demoralization, since the two constructs show almost the same strong positive correlation with suicidal thoughts, the two also being strongly correlated with each other.

Suicide Risk in Post-COVID-19 Syndrome

Post-acute sequelae of COVID-19 include several neuropsychiatric disorders. Little is known about the relationship between post-COVID-19 syndrome and suicidality. The aim of the study was to investigate the risk of suicide in subjects with persistent post-COVID-19 syndrome. One-thousand five-hundred eighty-eight subjects were assessed in the Post-Acute Care Service at the Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS of Rome. Assessment included: (a) sociodemographic characteristics; (b) symptoms during and after COVID-19; (c) psychopathological evaluation. Participants were divided in those with (SUI) or without (NON SUI) suicide risk according to the Mini International Neuropsychiatric Interview. Additionally, subjects with SUI were split into those with high (HIGH SUI) and low (LOW SUI) suicide risk. Between-group comparisons were made with t-tests for continuous variables and χ² tests for categorical variables. SUI showed greater percentages of physical complaints during and after COVID-19, greater percentages of psychiatric history and presence of psychiatric history in relatives, greater percentages of subjects previously undergoing psychopharmacotherapy, and greater levels of anxiety, mixed depressive symptoms, general psychopathology than NON SUI. HIGH SUI showed greater number of symptoms during and after COVID-19 and higher levels of mixed depressive symptoms than LOW SUI. Percentages of subjects undergoing psychotherapy was higher in LOW SUI than HIGH SUI. Greater levels of physical complaints and psychopathology during post-COVID-syndrome might enhance the risk of committing suicide. Treatment of physical complaints and psychotherapy might reduce suicide risk.

Pain, mood, and suicidal behavior among injured working adults in Chile

BACKGROUND

Chronic pain is comorbid with psychiatric disorders, but information on the association of chronic pain with depressive symptoms, generalized anxiety, and suicidal behavior among occupational cohorts is inadequate. We investigated these associations among employed Chilean adults.

METHODS

A total of 1946 working adults were interviewed during their outpatient visit. Pain was assessed using the Short Form McGill Pain questionnaire (SF-MPG) while depression and generalized anxiety were examined using the Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7), respectively. The Columbia-Suicide Severity Rating Scale was used to assess suicidal behavior and suicidal ideation. Multivariable logistic regression models were used to estimate adjusted odds ratios (aORs) and 95% confidence intervals (95%CI) for the association of chronic pain with mood disorders, as well as suicidal behavior.

RESULTS

High chronic pain (SF-MPG > 11) was reported by 46% of participants. Approximately two-fifths of the study participants (38.2%) had depression, 23.8% generalized anxiety, 13.4% suicidal ideation, and 2.4% suicidal behavior. Compared to those with low pain (SF-MPG ≤11), participants with high chronic pain (SF-MPG > 11) had increased odds of experiencing depression only (aOR = 2.87; 95% CI: 2.21-3.73), generalized anxiety only (aOR = 2.38; 95% CI: 1.42-3.99), and comorbid depression and generalized anxiety (aOR = 6.91; 95% CI: 5.20-9.19). The corresponding aOR (95%CI) for suicidal ideation and suicidal behavior were (aOR = 2.20; 95% CI: 1.58-3.07) and (aOR = 2.18 = 95% CI: 0.99-4.79), respectively.

CONCLUSIONS

Chronic pain is associated with increased odds of depression, generalized anxiety, and suicidal behavior. Mental health support and appropriate management of patients experiencing chronic pain are critical.

Possible Contribution of Meaning in Life in Patients With Chronic Pain and Suicidal Ideation: Observational Study

Background

Chronic pain is associated with an elevated risk of suicidal ideation (SI).

Objective

We aimed to examine if the presence or the search for Meaning in Life (MiL) are associated with less SI and explore whether MiL profiles emerge in our cohort. These profiles can be described as high presence–high search, high presence–low search, low presence–low search, and low presence–high search.

Methods

In this observational study, we recruited 70 patients who were referred to the Multidisciplinary Pain Center of the Geneva University Hospitals and who answered positively to question 9 on the Beck Depression Inventory, 2nd Edition, investigating SI. Patients who agreed to participate in the study were further investigated; they participated in a structured diagnostic interview to screen for psychiatric diagnoses. During this interview, they completed the Meaning in Life Questionnaire and the semistructured Scale for Suicide Ideation (SSI) to assess the characteristics and severity of SI.

Results

There was a statistically significant correlation between the presence of MiL subscale and the SSI. These 2 scales had a negative and statistically highly significant correlation (R=–.667; P<.001). The results also showed a negative and statistically highly significant correlation between the score of the search for MiL and the SSI (R=–.456; P<.001). The results thus pointed to the presence of MiL as a potential protective factor against the severity of SI, while the search for MiL is also a possible resiliency factor, although to a lesser extent. The profile low presence–low search grouped the vast majority (47%) of the patients; in these patients, the mean SSI score was 14.36 (SD 5.86), much higher compared with that of the other subgroups.

Conclusions

This study’s results point to MiL as a concept of interest regarding devising psychotherapeutic interventions for chronic pain patients in order to reduce the suicidal risk and more accurately determine patients’ suffering.

Pain, functional disability and mental disorders as potential mediators of the association between chronic physical conditions and suicidal ideation in community living older adults

OBJECTIVES

To examine the associations between chronic physical conditions and suicidal ideation and to assess whether associations are mediated by pain, anxiety, depression, post-traumatic stress syndrome (PTSS), and functional disability.

METHODS

The study sample includes 1533 older adults aged 65+ recruited in primary care clinics between 2011-2013 and participating in Quebec's Health Survey on Services "Étude sur la Santé des Aînés-Services" (ESA-S) study. Path analysis was used to assess the associations. The presence of suicidal behaviour was ascertained using 4 questions. PTSS was based on a validated scale for primary care older adults. Anxiety and depression were assessed according to DSM-IV criteria. Pain was self-reported on an ordinal scale and functional disability was based on the presence of disability in 8 dimensions of activities of daily living. The main predictors included a list of 13 physical disorders identified by diagnostic codes. Suicidal ideation was also controlled by a number of socio-demographic and psychosocial factors.

RESULTS

PTSS, depression, and functional disability mediate the association between various chronic conditions and suicidal ideation. Although pain and anxiety are associated with many physical disorders, they did not mediate the association with suicidal ideation.

CONCLUSIONS

Chronic physical disorders are associated with suicidal ideation, either directly or indirectly through PTSS, depression, and functional disability. The findings underscore the importance of early identification and management of older patients with specific chronic disorders in primary care as they may be most at risk for suicidal ideation.

Quality over quantity? The role of social contact frequency and closeness in suicidal ideation and attempt

BACKGROUND

Social support has been identified as a protective factor against suicidal thoughts and behaviors. Research has not conclusively identified the component of social support most implicated in suicidal thoughts and behaviors: (1) frequency of social contact or (2) closeness of relationships. This study examined the relationships between these facets of social support and suicidal thoughts and behaviors in two nationally representative samples, as well as subsamples with social anxiety disorder (SAD).

METHODS

Study 1 variables for lifetime and past-year suicide ideation and attempt, social contact frequency, and closeness were calculated and examined within the National Comorbidity Survey-Replication (NCS-R). Study 2 examined the independent contributions of social contact frequency and closeness to only lifetime suicide attempt in the National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III).

RESULTS

In the NCS-R, lower social closeness but not contact frequency was uniquely associated with suicidal ideation and attempt in the general sample and those with SAD. In the NESARC-III, both components of social support were associated with lifetime suicide attempt in the general sample, while only social closeness was uniquely associated with suicide attempt in the SAD subsample.

LIMITATIONS

This study utilized cross-sectional data and was limited in the validity and specificity of the variables assessed.

DISCUSSION

Lower social closeness was more strongly associated with suicidality than social contact frequency and merits attention as a potential target for suicide-related interventions. Social closeness may be especially relevant in populations experiencing high rates of suicidal thoughts and behaviors and decreased social support.

Exploring the comorbidity between personality and musculoskeletal disorders among adults: A scoping review

INTRODUCTION

There is growing awareness of the comorbidity between mental and musculoskeletal disorders (MSDs) and their associated burden. We aimed to explore what is known regarding the existing epidemiological clinical-and population- based literature on the comorbidity between personality disorders (PDs) and MSDs specifically. In addition, we aimed to investigate their associated burden by examining a range of outcomes including morbidity/mortality, patient- and clinical-reported outcomes, work-related outcomes, hospital admissions, and financial costs. Finally, we sought to identify gaps in the literature and provide recommendations for further research.

METHODS

Studies with participants 15 years of age were eligible. Categorical PDs/features (DSM-III/IV/5 or ICD 9/10), identified by a health care professional, medical records, diagnostic interviews, or self-administered questionnaires. The definitions/groupings of MSDs were guided by the ICD-10 including conditions of the back, joints, and soft tissue, and disorders of bone density and structure. Published peer-reviewed and gray literature were considered. Eligible study designs were cohort, case-control, and cross-sectional studies, and existing reviews of observational studies. Identification and selection of articles, data extraction and the presentation of the results was conducted according to the Joanna Briggs Institute methodological guidance and the PRISMA extension for scoping reviews.

RESULTS

In total, 57 articles were eligible including 10 reviews and 47 individual studies. Across clinical and population settings, we detected evidence of comorbidity between PDs and chronic back/neck/spine conditions, arthritis, and fibromyalgia, and emerging evidence of associations between PDs and reduced bone mineral density. In terms of knowledge gaps, the burden associated with PDs and MSDs is poorly understood, as is their underlying mechanisms.

DISCUSSION

This scoping review might prompt further research into PDs and MSDs as separate groups of disorders, along with their comorbidity and the mechanisms that may link them.

SYSTEMATIC REVIEW REGISTRATION

https://osf.io/mxbr2/registrations.

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.

Identifying and Managing Suicidality in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome

Adult patients affected by myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) are at an increased risk of death by suicide. Based on the scientific literature and our clinical/research experiences, we identify risk and protective factors and provide a guide to assessing and managing suicidality in an outpatient medical setting. A clinical case is used to illustrate how information from this article can be applied. Characteristics of ME/CFS that make addressing suicidality challenging include absence of any disease-modifying treatments, severe functional limitations, and symptoms which limit therapies. Decades-long misattribution of ME/CFS to physical deconditioning or psychiatric disorders have resulted in undereducated healthcare professionals, public stigma, and unsupportive social interactions. Consequently, some patients may be reluctant to engage with mental health care. Outpatient medical professionals play a vital role in mitigating these effects. By combining evidence-based interventions aimed at all suicidal patients with those adapted to individual patients' circumstances, suffering and suicidality can be alleviated in ME/CFS. Increased access to newer virtual or asynchronous modalities of psychiatric/psychological care, especially for severely ill patients, may be a silver lining of the COVID-19 pandemic.

The Role of Demoralization and Meaning in Life (DEMIL) in Influencing Suicidal Ideation Among Patients Affected by Chronic Pain: Protocol of a Single-Center, Observational, Case-Control Study

BACKGROUND

Chronic pain is a significant risk factor for suicidal ideation (SI) and suicidal behavior (SB), including a 20%-40% prevalence rate of SI, a prevalence between 5% and 14% of suicide attempts, and a doubled risk of death by suicide in patients with chronic pain compared to controls. In most studies, associations between chronic pain and suicidality are robust, even after adjusting for the effect of sociodemographics and psychiatric comorbidity, and particularly for depressive conditions. A number of specific conditions that can modulate suicidality risk in patients with chronic pain have been investigated, but there is a need for their more specific characterization. Numerous recent studies have shown that demoralization and meaning in life (MiL) constructs affect suicidality as risk and protective factors, respectively. These constructs have been mainly investigated in patients with somatic illness and in community-dwelling individuals who may present with SI or SB independently of a psychiatric diagnosis of depression. However, a paucity of studies investigated them in suicidal patients affected by chronic pain.

OBJECTIVE

The primary objective of this project is to investigate the relationship between demoralization and MiL on SI risk in patients with chronic pain. The secondary objectives are (1) to test whether demoralization can occur independently of depression in patients with chronic pain and SI, (2) to examine whether the expected association between demoralization and SI may be explained by a sole dimension of demoralization: hopelessness, (3) to examine whether the presence of MiL, but not the search for MiL, is associated with less SI, and (4) to explore whether previously described MiL profiles (ie, high presence-high search, high presence-low search, moderate presence-moderate search, low presence-low search, and low presence-high search) emerge in our cohort.

METHODS

This project is a single-center, observational, case-control study-the Demoralization and Meaning in Life (DEMiL) study-conducted by the Division of Clinical Pharmacology and Toxicology, the Multidisciplinary Pain Centre, and the Service of Liaison Psychiatry and Crisis Intervention at the Geneva University Hospitals. Self- and hetero-administered questionnaires were conducted among patients and controls, matched by age and gender. The Ethics Committee of the Canton of Geneva approved the scientific utilization of collected data (project No. 2017-02138; decision dated January 25, 2018). Data have been analyzed with SPSS, version 23.0, software (IBM Corp).

RESULTS

From March 1, 2018, to November 30, 2019, 70 patients and 70 controls were enrolled. Statistical analyses are still in progress and are expected to be finalized in November 2020. To date, we did not observe any unfavorable event for which a causal relationship with the collection of health-related personal data could be ruled out. Results of this study are expected to form the basis for possible prevention and psychotherapeutic interventions oriented toward demoralization and MiL constructs for suicidal patients with chronic pain.

CONCLUSIONS

The interest in exploring demoralization and MiL in chronic pain patients with SI arises from the common clinical observation that experiencing chronic pain often requires a revision of one's life goals and expectations. Hence, the impact of chronic pain is not limited to patients' biopsychosocial functioning, but it affects the existential domain as well. The major clinical implications in suicidal patients with chronic pain consist in trying to (1) delineate a more precise and individualized suicide risk profile, (2) improve detection and prevention strategies by investigating SI also in individuals who do not present with a clinically diagnosed depression, and (3) enhance the panel of interventions by broadening supportive or psychotherapeutic actions, taking into consideration the existential condition of a person who suffers and strives to deal with his or her suffering.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/24882.

Exploring the links among borderline personality disorder symptoms, trauma, and pain in patients with chronic pain disorders

OBJECTIVE

Chronic pain and borderline personality disorder (BPD) are commonly comorbid and jointly associated with increased symptoms of both disorders and clinical and functional impairment. Little is known, however, about specific links between these disorders. In a cross-sectional study of patients with chronic pain, we compared participants high or low on BPD symptoms on patterns of pain experience and types of child and adult traumas.

METHODS

Adults (N = 181) with chronic pain completed self-reports of pain severity, dimensions of pain experiencing, body coverage of pain, and clinical indicators of central sensitization (i.e., chronic hypersensitivity of the central nervous system), as well as measures of child and adult physical abuse, sexual abuse, trauma, and neglect. Participants also completed the McLean Screening Instrument for BPD.

RESULTS

Participants with clinically significant BPD symptoms (n = 32) reported more childhood sexual trauma, punishment, and neglect, as well as adult physical/sexual trauma, than those without elevated BPD symptoms. Among participants with clinically significant BPD symptoms, affective pain and central sensitization were elevated, potentially explained by heightened negative affect in BPD.

CONCLUSION

BPD symptoms are associated with increased clinical severity among patients with chronic pain as well as a unique manifestation of pain experiencing (i.e., increased affective pain and central sensitization in particular). Childhood trauma of all types is associated with chronic pain and BPD co-occurrence. Researchers and clinicians should assess for BPD in people with chronic pain to enhance conceptual models of the transaction between these disorders and to improve clinical care.

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.

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.

Stopping or Decreasing Opioid Therapy in Patients on Chronic Opioid Therapy

With the rising concerns about long-term opioid use, particularly in patients with chronic noncancer pain, more and more patients are being considered for decreased doses or discontinuation of opioid therapy. This is a challenging clinical situation for both patient and clinician and should be presented in a shared decision-making model so that the patient understands the risks of opioid therapy and how the therapy will be discontinued. The patient should be aware of the long-range plan and its milestones. It is imperative that alternate pain control treatments be made available to the patient early, and that the patient never feels abandoned by the healthcare team. There can be many barriers in shared decision-making and multiple discussions between patient and provider may be required. Opioid use should not be decreased sharply or discontinued abruptly, but should be gradually decremented in a process known as tapering. Tapering should be systematic and planned in advance with the patient knowing the steps. Slow tapers (over months) are more comfortable for the patients but may not always be appropriate. There is guidance for planning the taper and the patient should be closely monitored throughout this process. If withdrawal symptoms occur, they can be managed, for example, with lofexidine. Patients should get full support as they explore new pain control options. For patients who have opioid use disorder, addiction counseling may be appropriate. Navigating opioid discontinuation can be slow work, but optimal results occur when the healthcare team works together and respectfully with the patient.

Clinical characteristics of veterans with gambling disorders seeking pain treatment

OBJECTIVES

To examine the relationships between gambling disorder, pain, and suicide attempts among US military veterans using Veterans Health Administration (VHA) pain-related services.

METHODS

Retrospective cohort analysis of 221,817 veterans using pain services was included in the analysis. First, differences in sociodemographic and clinical characteristics (i.e., psychiatric comorbidities and pain-related variables) were analyzed according to gambling disorder. Second, we performed logistic regression analyses to assess the association between gambling disorder and suicide attempts.

RESULTS

Female sex, depressive, alcohol, drug and tobacco use disorders are positively associated with gambling disorders, while severe pain score is negatively associated with gambling disorders. Logistic regression analysis showed that gambling disorder diagnosis was associated suicide attempt in veterans who received a visit for pain in VHA in the past year.

CONCLUSIONS

Our findings suggest that gambling disorder in female veterans and suicide attempts in veterans with gambling disorder should not be underestimated and warrants further consideration. Moreover, the result that veterans with severe pain may be less likely to have a diagnosis of gambling disorder needs to be confirmed.

Opioid Use and Misuse and Suicidal Behaviors in a Nationally Representative Sample of US Adults

Prior research has shown associations between opioid misuse and suicidal behaviors, but the relationship between medical opioid use and suicidal behaviors is not known. We assessed associations of opioid use and misuse with suicidal ideation, suicide plans, and suicide attempts among adults aged 18-64 years (n = 86,186) using nationally representative cross-sectional data from the 2015 and 2016 administrations of the National Survey on Drug Use and Health. We used logistic regression to estimate associations between opioid use/misuse and suicidal behaviors and propensity score-weighted logistic regression analysis to examine the counterfactual scenario in which persons with misuse had instead not misused opioids. In propensity score-weighted analyses, compared with opioid misuse, opioid use without misuse was associated with lower odds of suicidal ideation (odds ratio (OR) = 0.57, 95% confidence interval (CI): 0.45, 0.72) and suicide plans (OR = 0.53, 95% CI: 0.35, 0.80), and no use was associated with lower odds of suicidal ideation (OR = 0.62, 95% CI: 0.49, 0.80), suicide plans (OR = 0.56, 95% CI: 0.39, 0.79), and suicide attempts (OR = 0.54, 95% CI: 0.33, 0.89). These findings suggest that opioid misuse is associated with greater odds of suicidal behaviors, but opioid use without misuse is not. Compared with persons with opioid misuse, similar persons without misuse have a reduced risk of suicidal behaviors. Clinical and public health interventions should focus on preventing misuse of opioids.

Remission From Suicidal Ideation Among Those in Chronic Pain: What Factors Are Associated With Resilience?

Although there have been many studies on the link between chronic pain and suicidality, surprisingly little research has focused on resilience and recovery among those in chronic and disabling pain who have had suicidal thoughts. The objectives of this study were to identify the prevalence and correlates of recovery from suicidal thoughts among those in chronic pain. A secondary analysis of a nationally representative sample of Canadians in chronic and disabling pain who had ever had serious suicidal thoughts (N = 635) was conducted to identify the prevalence and characteristics of those who are no longer considering suicide. Data were drawn from the Canadian Community Health Survey-Mental Health. Three in five Canadians in chronic pain (63%) who had seriously considered suicide at some point in their life had been free of these thoughts in the past year. Those free of suicidal ideation were significantly more likely to be older, women, white, better educated, with a confidant, and to use spirituality to cope, but less likely to have low household incomes, difficulties meeting basic expenses, and a history of depression and anxiety disorders. PERSPECTIVE: Almost two-thirds of formerly suicidal Canadians with chronic pain were free from suicidal thoughts in the past year. These findings provide a hopeful message of resilience and recovery in the context of disabling pain and help to improve targeted outreach to those most at risk for unremitting suicidality.

Multiple types of somatic pain increase suicide attempts and depression: A nationwide community sample of Korean adults

OBJECTIVE

Somatic pain is an important risk factor for suicide and suicidal behaviors. However, the association between the number of somatic pain conditions and lifetime suicide attempts (LSA) has not been well established yet. Therefore, the objective of this study was to examine associations between LSA and multiple somatic pain (MSP), singe pain, and no pain in a nationwide survey.

METHODS

A total of 12,532 adults were randomly selected from the population using the one-person-per-household method. Each participant completed a face-to-face interview using the Korean Composite International Diagnostic Interview (K-CIDI) with Suicide Module, and the Barratt Impulsiveness Scale 11 (BIS-11). The MSP was defined as pain in two or more parts of one's body, including abdominal pain, back pain, arthralgia, arm or leg pain, chest pain, headache, menstrual pain, dysuria, genital pain, and other pain.

RESULTS

Among 12,532 subjects, 858 (6.85%) had MSP. Among the three groups (MSP, single pain, and no pain) of subjects, the MSP group had higher percentages of females, those with lower education, and divorced/widowed/separated individuals. However, there were no significant differences in monthly income or residence among the three groups. The MSP group showed four times higher suicide attempts and six times higher multiple attempts than did the no pain group. The BIS total score of the MSP group was the highest among the three groups. Genital pain showed the highest odds ratio for LSA. The higher the number of somatic pain, the higher the odds ratios were for LSA, major depressive disorder (MDD), and anxiety disorders. Subjects having both MSP and MDD showed a significant association with LSA (AOR = 14.78, 95% CI 10.08-21.67, p < 0.001) compared to those having neither somatic pain nor MDD.

CONCLUSIONS

MSP was significantly associated with LSA. It had greater prevalence among individuals reporting a higher number of somatic pain conditions and comorbid MDD.

The Mediating Effect of Sleep Disturbance on the Relationship Between Nonmalignant Chronic Pain and Suicide Death

IMPORTANCE

Few studies have examined the relationship between nonmalignant chronic pain (NMCP) and suicide death, and even fewer have specifically explored what role sleep disturbance might play in the association between NMCP and suicide death.

OBJECTIVE

To assess whether sleep disturbance mediates the relationship between NMCP and suicide death.

DESIGN

This case-control study included 2,674 individuals who died by suicide between 2000 and 2013 (cases) and 267,400 matched individuals (controls).

SETTING

Eight Mental Health Research Network (MHRN)-affiliated healthcare systems.

PARTICIPANTS

All cases and matched controls were health plan members for at least 10 months during the year prior to the index date.

MAIN OUTCOMES AND MEASURES

Sociodemographic data and diagnosis codes for NMCP and sleep disorders were extracted from the MHRN's Virtual Data Warehouse. Suicide mortality was identified using International Statistical Classification of Diseases and Related Health Problems (ICD)-10 codes from official government mortality records matched to health system records.

RESULTS

After accounting for covariates, there was a significant relationship between NMCP and sleep disturbance; those who were diagnosed with NMCP were more likely to develop subsequent sleep disturbance. Similarly, sleep disturbance was significantly associated with suicide death. Finally, a significant indirect effect of NMCP on suicide death, through sleep disturbance, and a nonsignificant direct effect of NMCP on suicide death provide support for a fully mediated model.

CONCLUSIONS AND RELEVANCE

There is a need for clinicians to screen for both sleep disturbance and suicidal ideation in NMCP patients and for health systems to implement more widespread behavioral treatments that address comorbid sleep problems and NMCP.

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.

Evidence-Based Practice Guideline: Secondary Prevention of Late-Life Suicide

Suicide is a tragic, traumatic loss, and one of the most emotionally devastating events families, friends, and communities experience. Suicide claims more than 800,000 lives every year, and some of the highest rates of suicide in the United States and globally are among older adults. The purpose of this evidence-based guideline is to help health care providers recognize those at risk for suicide and recommend appropriate and effective secondary suicide prevention interventions. The information in this guideline is intended for health care providers who work in a variety of settings, including hospitals, nursing homes, rehabilitation centers, out-patient clinics, mental health clinics, home health care, and other long-term care facilities. Assessment and preventive treatment strategies were derived by exhaustive literature review and synthesis of the current evidence on secondary prevention of late-life suicide across practice settings. [Journal of Gerontological Nursing, 44(11), 20-32.].

Anti-nociceptive interactions between opioids and a cannabinoid receptor 2 agonist in inflammatory pain

The cannabinoid 1 receptor and cannabinoid 2 receptor can both be targeted in the treatment of pain; yet, they have some important differences. Cannabinoid 1 receptor is expressed at high levels in the central nervous system, whereas cannabinoid 2 receptor is found predominantly, although not exclusively, outside the central nervous system. The objective of this study was to investigate potential interactions between cannabinoid 2 receptor and the mu-opioid receptor in pathological pain. The low level of adverse side effects and lack of tolerance for cannabinoid 2 receptor agonists are attractive pharmacotherapeutic traits. This study assessed the anti-nociceptive effects of a selective cannabinoid 2 receptor agonist (JWH-133) in pathological pain using mice subjected to inflammatory pain using the formalin test. Furthermore, we examined several ways in which JWH-133 may interact with morphine. JWH-133 produces dose-dependent anti-nociception during both the acute and inflammatory phases of the formalin test. This was observed in both male and female mice. However, a maximally efficacious dose of JWH-133 (1 mg/kg) was not associated with somatic withdrawal symptoms, motor impairment, or hypothermia. After eleven once-daily injections of 1 mg/JWH-133, no tolerance was observed in the formalin test. Cross-tolerance for the anti-nociceptive effects of JWH-133 and morphine were assessed to gain insight into physiologically relevant cannabinoid 2 receptor and mu-opioid receptor interaction. Mice made tolerant to the effects of morphine exhibited a lower JWH-133 response in both phases of the formalin test compared to vehicle-treated morphine-naïve animals. However, repeated daily JWH-133 administration did not cause cross-tolerance for morphine, suggesting opioid and cannabinoid 2 receptor cross-tolerance is unidirectional. However, preliminary data suggest co-administration of JWH-133 with morphine modestly attenuates morphine tolerance. Isobolographic analysis revealed that co-administration of JWH-133 and morphine has an additive effect on anti-nociception in the formalin test. Overall these findings show that cannabinoid 2 receptor may functionally interact with mu-opioid receptor to modulate anti-nociception in the formalin test.

The role of psychological flexibility in relation to suicidal thinking in chronic pain

BACKGROUND

Suicidal thinking (ST) is common in people with chronic pain. It is relevant as it can be associated with suicidal attempts, and typically reflects significant suffering. While little is known about the psychological processes that contribute to ST, current psychological models, such as the Psychological Flexibility (PF) model, could help guide further investigation. This study investigates relations between ST and components of PF in chronic pain.

METHODS

Participants were 424 adults attending treatment for chronic pain in the UK. Included in measures administered before treatment were standardized measures of depression, pain, pain-related interference, and measures of PF, including acceptance, cognitive defusion, committed action, and self-as-context. An item from the measure of depression was used to reflect ST.

RESULTS

A large proportion of the sample reported ST, 45.7%. ST was uncorrelated with participant background characteristic, medications taken, or pain intensity. However, it was correlated with the presence of widespread pain, pain-related interference, and depression. Each component of PF was found to be significantly negatively associated with ST, as predicted. General acceptance correlated with ST at a level equal to that achieved by the depression score. In adjusted multivariate logistic regression general acceptance and committed action remained significantly uniquely associated with it.

CONCLUSION

This preliminary study suggests for the first time that components of PF are associated with part of a pattern of suicidal behaviour in people with chronic pain. They may be relevant for reducing avoidance in general and providing more positive behavioural options.

SIGNIFICANCE

This study provides evidence that components of psychological flexibility are associated with a reduced frequency of suicidal thinking in people with chronic pain. Treatments targeting psychological flexibility may help mitigate the impact of chronic pain on suicidal thinking.

A population-based examination of the co-occurrence and functional correlates of chronic pain and generalized anxiety disorder

OBJECTIVES

This study aimed to: 1) Establish the prevalence of co-occurring chronic pain conditions (i.e., arthritis, back pain, and migraines) and generalized anxiety disorder (GAD), and 2) Examine levels of pain severity, disability, and work absenteeism among comorbid chronic pain conditions and GAD.

METHODS

Data were analyzed from the 2012 Canadian Community Health Survey-Mental Health (CCHS-MH; N = 25,113). Chi-square analyses assessed whether significant differences existed in pain severity in those with comorbid chronic pain and GAD versus pain conditions alone. Multivariable regressions examined the association between comorbid chronic pain and GAD with functional outcomes.

RESULTS

The weighted prevalence of GAD among those with chronic migraines, arthritis and back pain was 6.9%, 4.4%, and 6.1% respectively, compared to 2.6% among the entire sample. Severity of pain was increased among those with comorbid chronic pain and GAD compared with chronic pain conditions alone. Migraine was the only pain condition that was significantly associated with disability in our most stringent adjustment model. After controlling for other psychiatric disorders, comorbid GAD and chronic pain was not associated with work absenteeism.

CONCLUSION

Chronic pain is common among the Canadian population and is associated with substantial disability. Results demonstrated that GAD is prevalent among chronic pain conditions, and comorbidity is associated with greater pain severity. GAD in the context of migraines, in particular, may represent an important treatment target to reduce disability.

Suicide Behavior and Chronic Pain: An Exploration of Pain-Related Catastrophic Thinking, Disability, and Descriptions of the Pain Experience

This study examined differences in suicidal ideation (SI) and suicide attempts (SAs) among veterans with chronic pain. Pain-specific variables, including catastrophic thinking, disability, and sensory, affective, and evaluative pain descriptors, were a focus. Structured diagnostic and clinical interviews were conducted to examine SI/SA and mental health. Veterans completed the Structured Clinical Interview for DSM-IV and the Columbia-Suicide Severity Rating Scale to assess Axis I symptoms and suicidal behavior(s). Self-report questionnaires were used to evaluate the participants' subjective experience of chronic pain, which included the McGill Pain Questionnaire, Pain Catastrophizing Scale, and Pain Disability Index. The findings add to previous literature by suggesting pain-related catastrophic thinking specifically is related to elevated risk for SA, whereas affective and sensory pain are associated with SI. The study results support the need to assess pain from a multifaceted perspective and to examine the different experiences of pain, such as sensory and affective constructs, when discussing suicide risk in veterans.

The association between pain and suicidal behavior in an English national sample: The role of psychopathology

Pain has been linked with an increased risk of engaging in suicidal behavior. However, the role of common mental disorders (CMDs) and borderline personality disorder (BPD) traits in this association is largely unknown. This study was based on data from the 2007 Adult Psychiatric Morbidity Survey (N = 7403). Suicidal behavior referred to past 12-month suicidal ideation and suicide attempt. Pain was assessed in terms of the level of its interference with work activity in the past four weeks. BPD traits were assessed with the structured interview for DSM disorders questionnaire, and CMDs with the Clinical Interview Schedule Revised (CIS-R). Multivariate logistic regression and mediation analyses were conducted to analyze the association between pain and suicidal behavior, and the role of CMDs and BPD traits in this association. The prevalence of past 12-month suicidal ideation and suicide attempt increased from 2.7% to 11.5% and 0.2% to 2.4%, respectively, between no pain and extreme pain. Pain was found to be significantly associated with suicidal ideation (ORs = 1.61-2.92) and suicide attempt (ORs = 2.95-6.70). CMDs were significant mediators in the pain-suicidal behavior relationship but did not fully explain the association. BPD had little influence in this association. Assessing suicide risk in individuals with pain may be important for suicide prevention. Treating CMDs may reduce risk for suicide in these individuals but other factors leading to higher risk for suicidal behavior should also be investigated in future studies.

Recent advances in understanding physical health problems in personality disorders

Personality disorders are associated with a range of adverse health outcomes, contributing to the high healthcare utilization seen in patients with these disorders. A growing literature supports a robust association of personality disorders and health problems. The primary aim of this article is to summarize the most recent research documenting the associations between personality disorders and health conditions. Extending past reviews, we discuss the association of personality disorders with chronic physical illnesses, sleep disturbances, pain conditions, and obesity. We provide recommendations for future research in this area.

Emotion Dysregulation Mediates the Relation Between Borderline Personality Disorder Symptoms and Later Physical Health Symptoms

Despite evidence of a relation between borderline personality disorder (BPD) pathology and physical health problems, the mechanisms underlying this relation remain unclear. Given evidence that emotion dysregulation may affect physical health by altering physiological functioning, one mechanism that warrants examination is emotion dysregulation. This study examined BPD symptoms as a prospective predictor of physical health symptoms 8 months later and the mediating role of emotion dysregulation in this relation. Participants completed three assessments over an 8-month period, including a BPD diagnostic interview. Results of analyses examining baseline predictors of later physical health symptoms revealed a significant unique association between baseline BPD symptom severity and physical health symptoms 8 months later, above and beyond baseline physical health symptoms, depression and anxiety symptoms, and emotion dysregulation. Moreover, structural equation modeling revealed a significant indirect relation of BPD symptoms at Wave 1 to physical health symptoms at Wave 3 through emotion dysregulation at Wave 2.

Neurophysiologic Correlates of Headache Pain in Subjects With Major Depressive Disorder

BACKGROUND

Headache pain is often comorbid with major depressive disorder (MDD) and is associated with greater symptom burden, disability, and suicidality. The biological correlates of headache pain in MDD, however, remain obscure. The purpose of this study was to examine the association between brain oscillatory activity and headache pain in MDD subjects.

METHODS

A total of 64 subjects with MDD who were free of psychoactive medications were evaluated for severity of headache pain in the past week. Brain function was assessed using resting-state quantitative electroencephalography (qEEG). We derived cordance in the theta (4-8 Hz) and alpha (8-12 Hz) frequency bands at each electrode, and examined correlations with headache pain in regions of interest while controlling for depression severity. Frontal and posterior asymmetry in alpha power was calculated in regions of interest.

RESULTS

Headache pain severity was associated with depression severity ( r = 0.447, P < .001). In bilateral frontal and right posterior regions, alpha cordance was significantly associated with headache intensity, including when controlling for depression severity. The direction of the correlation was positive anteriorly and negative posteriorly. Frontal left dominant alpha asymmetry correlated with severity of headache but not depression symptoms.

CONCLUSION

Alterations in brain oscillations identified by alpha cordance and alpha asymmetry may be associated with the pathophysiology of headache pain in depression. These findings should be prospectively confirmed.

The multi-factorial origins of Chronic Traumatic Encephalopathy (CTE) symptomology in post-career athletes: The athlete post-career adjustment (AP-CA) model

CTE has two prominent components: the pathophysiology that is detected in the brain postmortem and the symptomology that is present in the interval between retirement and end of life. CTE symptomology has been noted to include memory difficulties, aggression, depression, explosivity, and executive dysfunction at early stages progressing to problems with attention, mood swings, visuospatial difficulties, confusion, progressive dementia, and suicidality (e.g. McKee et al. (2012), Omalu et al. (2010a-c), McKee et al. (2009)). There are a number of assumptions embedded within the current CTE literature: The first is the assumption that CTE symptomology reported by athletes and their families is the product of the pathophysiology change detected post-mortem (e.g. McKee et al. (2009)). At present, there is little scientific evidence to suggest that all CTE symptomology is the product of CTE pathophysiology. It has been assumed that CTE pathophysiology causes CTE symptomology (Meehan et al. (2015), Iverson et al. (2016)) but this link has never been scientifically validated. The purpose of the present work is to provide a multi-factorial theoretical framework to account for the symptomology reported by some athletes who sustain neurotrauma during their careers that will lead to a more systematic approach to understanding post-career symptomology. There is significant overlap between the case reports of athletes with post-mortem diagnoses of CTE, and symptom profiles of those with a history of substance use, chronic pain, and athlete career transition stress. The athlete post-career adjustment (AP-CA) model is intended to explain some of the symptoms that athletes experience at the end of their careers or during retirement. The AP-CA model consists of four elements: neurotrauma, chronic pain, substance use, and career transition stress. Based on the existing literature, it is clear that any one of the four elements of the AP-CA model can account for a significant number of CTE symptoms. In addition, depression can be a chronic lifelong co-morbid condition that may be present prior to an athletic career, or may be developed secondary to any of the model elements as shown in Fig. 1. Notably, neurotrauma is a necessary, but not a sufficient condition, for the development of CTE symptomology.

The role of physical and mental health multimorbidity in suicidal ideation

BACKGROUND

Previous research has focused on the separate roles of mental illness and physical health conditions in suicide risk, with relatively few studies investigating the importance of physical and psychiatric disorder co-occurrence. We aimed to investigate whether suicidal ideation might be influenced by physical and mental ill-health multimorbidity.

METHODS

Data from the Adult Psychiatric Morbidity Survey of England were analysed. Participants who responded to the suicidal thoughts question were grouped into four distinct categories based on their health conditions (Common mental disorders (CMD) only, physical health conditions only, CMD/physical health multimorbidity and a control group with neither physical nor mental health conditions). Multinomial logistic regression analyses were conducted and odds ratios (OR) and 95% CIs are presented.

RESULTS

In the fully adjusted model, both the multimorbidity and CMD-only groups were associated with higher levels of suicidal ideation relative to the control group.

LIMITATIONS

Secondary analyses of cross-sectional data.

CONCLUSIONS

Although multimorbidity was associated with suicidal thoughts, it does not appear to elevate risk beyond the independent effects of common mental disorders or physical health problems. Primary care and mental health clinicians should consider assessment of suicidal ideation among patients with multimorbid physical/mental health conditions.

Prevalence and Correlates of Suicidal Thoughts and Suicide Attempts in People Prescribed Pharmaceutical Opioids for Chronic Pain

OBJECTIVES

The main objectives of the paper were (1) to examine the prevalence of suicidality in a large community-based chronic pain sample taking prescribed opioids for chronic pain; and (2) to examine general and pain-specific factors that predict such ideation, and the transition from ideation to making a suicide attempt (ideation-to-action).

MATERIALS AND METHODS

Baseline data from the Pain and Opioids IN Treatment (POINT) study with a cohort of 1514 community-based people prescribed opioids for chronic noncancer pain across Australia.

RESULTS

Past 12-month suicidal ideation was reported by 36.5% of the cohort and 16.4% had made a lifetime suicide attempt (2.5% in the last 12 mo), after the onset of their pain condition. Suicidal ideation in the past 12 months was independently associated with a past suicide attempt [adjusted odds ratio (AOR)=4.82; 95% confidence interval, 2.43-9.56] and past 12-month depression (AOR=4.07, 95% confidence interval, 1.88-8.78). Only a lower pain self-efficacy score was independently associated with past 12-month ideation-to-action (AOR=0.98, 95%CI0.88-0.99). Notably, only general-suicide risk factors were associated with 12-month suicidal ideation; but for past year ideation-to-action, pain-specific factors also had independent associations.

DISCUSSION

The study is one of the first to comprehensively examine general and pain-specific risk factors for suicidality in a large chronic pain sample in which suicidal ideation was common. A low pain self-efficacy score was the only factor independently associated past 12-month ideation-to-action.

Serious Suicide Attempts: Evidence on Variables for Manage and Prevent this Phenomenon

The aim of this study is to investigate the variables shown to be linked to serious suicide attempts. Cases requiring emergency admission to intensive care were collected from medical records of the University Hospital in Messina (Italy) for the years 2006-2010. 107 cases of serious attempted suicide were examined, 39 of which ended in the death of the patient. The results showed the following variables to be linked highly significantly (P < 0.01) and have good nominal association (V > 0.30) with a fatal suicidal attempt: the year of the attempt, deceased father, history of physical illness prior to hospitalization and method used to carry out the suicide attempt. These results confirm the severity and the multidisciplinary importance of this phenomenon.

Ketamine for Treatment of Suicidal Ideation and Reduction of Risk for Suicidal Behavior

Ketamine, an NMDA receptor antagonist with efficacy as a rapid anti-depressant, has early evidence for action to reduce suicidal ideation. This review will explore several important questions that arise from these studies. First, how do we measure reductions in suicidal ideation that occur over minutes to hours? Second, are the reductions in suicidal ideation after ketamine treatment solely a result of its rapid anti-depressant effect? Third, is ketamine only effective in reducing suicidal ideation in patients with mood disorders? Fourth, could ketamine's action lead us to a greater understanding of the neurobiology of suicidal processes? Last, do the reductions in depression and suicidal ideation after ketamine treatment translate into decreased risk for suicidal behavior? Our review concludes that ketamine treatment can be seen as a double-edged sword, clinically to help provide treatment for acutely suicidal patients and experimentally to explore the neurobiological nature of suicidal ideation and suicidal behavior.

Suicide attempts among alcohol-dependent pain patients before and after an inpatient hospitalization

BACKGROUND

This study examined (1) whether pain diagnoses were risk factors for non-fatal suicide attempts before and after inpatient hospitalizations in alcohol-dependent veterans, and (2) the characteristics of pain patients who attempted suicide.

METHOD

Administrative data from the Veterans Health Administration were used to identify veterans with an alcohol use disorder who had an inpatient hospitalization during fiscal year 2011 (n=13,047). Logistic regression analyses were used to examine the associations of suicide attempts before and after hospitalizations with pain diagnoses, demographics, medical comorbidity, and psychiatric comorbidity.

RESULTS

Bivariate analyses and analyses controlling for demographics and medical comorbidity, indicated that pain diagnoses were significantly associated with suicide attempts in the 365days before hospitalization (Odds Ratio Adjusted [OR]=1.22). This effect was not significant after controlling for psychiatric disorders. Pain diagnoses were not identified as risk factors of suicide attempts in the 365days following discharge. Subgroup analyses among only those with a pain diagnosis revealed that being younger (OR=2.64), being female (OR=2.28), and having an attempt in the year prior to hospitalization (OR=4.11) were risk factors of suicide attempts in the year following hospitalization. Additionally, younger age (OR=2.13) and depression (OR=3.53) were associated with attempts in the year prior to the hospitalization.

CONCLUSIONS

This study suggests that psychiatric disorders account for the relationship between pain diagnoses and past suicide attempts among hospitalized alcohol-dependent veterans. Pain-specific suicide prevention efforts may be better targeted at less intensive levels of care.

High-frequency intimate partner violence during pregnancy, postnatal depression and suicidal tendencies in Harare, Zimbabwe

INTRODUCTION

Intimate partner violence (IPV) is a common form of violence experienced by pregnant women and is believed to have adverse mental health effects postnatally. This study investigated the association of postnatal depression (PND) and suicidal ideation with emotional, physical and sexual IPV experienced by women during pregnancy.

METHODS

Data were collected from 842 women interviewed postnatally in six postnatal clinics in Harare, Zimbabwe. We used the World Health Organization versions of IPV and Centre for Epidemiological Studies - Depression Scale measures to assess IPV and PND respectively. We derived a violence severity variable and combined forms of IPV variables from IPV questions. Logistic regression was used to analyse data whilst controlling for past mental health and IPV experiences.

RESULTS

One in five women [21.4% (95% CI 18.6-24.2)] met the diagnostic criteria for PND symptomatology whilst 21.6% (95% CI 18.8-24.4) reported postpartum suicide thoughts and 4% (95% CI 2.7-5.4) reported suicide attempts. Two thirds (65.4%) reported any form of IPV. Although individual forms of severe IPV were associated with PND, stronger associations were found between PND and severe emotional IPV or severe combined forms of IPV. Suicidal ideation was associated with emotional IPV. Other forms of IPV, except when combined with emotional IPV, were not individually associated with suicidal ideation.

CONCLUSION

Emotional IPV during pregnancy negatively affects women's mental health in the postnatal period. Clinicians and researchers should include it in their conceptualisation of violence and health. Further research must look at possible indirect relationships between sexual and physical IPV on mental health.