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Manning FM, Mughal F, Ismail HASM, Baines LM, Chew-Graham CA, Paskins Z, Prior JA. Osteoporosis and fracture as risk factors for self-harm and suicide: a systematic review and meta-analysis. Br J Gen Pract 2023; 73:e735-e743. [PMID: 37722857 PMCID: PMC10523335 DOI: 10.3399/bjgp.2023.0035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 07/03/2023] [Indexed: 09/20/2023] Open
Abstract
BACKGROUND Increase in presentations of self-harm to primary care, a risk factor of suicide, has led to a growing interest in identifying at-risk populations. AIM To examine whether osteoporosis or fractures are risk factors for self-harm, suicidal ideation, and suicide. DESIGN AND SETTING This was a systematic review of observational studies in adults (>18 years) that had examined the role of osteoporosis and/or fractures in subsequent self-harm, suicidal ideation, and/or suicide. METHOD Six databases were searched from inception to July 2019. Additional citation tracking of eligible studies was undertaken in November 2022. Screening, data extraction, and quality assessment of full-text articles were performed independently by at least two authors. Where possible, meta-analysis was run on comparable risk estimates. RESULTS Fifteen studies were included: two examined the outcome of self-harm, three suicidal ideation, and 10 suicide. In approximately half of studies on osteoporosis, the risk of suicidal ideation and suicide remained significant. However, pooling of adjusted odds ratios from three studies indicated no association between osteoporosis and suicide (1.14, 95% confidence interval = 0.88 to 1.49). Nine studies examined the risk of a mixture of fracture types across different outcomes, limiting comparisons. However, all studies examining vertebral fracture (n = 3) reported a significant adjusted negative association for self-harm and suicide. CONCLUSION Patients with vertebral fractures, a risk potential factor for suicide, may benefit from clinical case finding for mood disorders with personalised primary care management. However, because of the limited number and quality of studies and mixed findings, further examination of these associations is warranted.
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Affiliation(s)
- Fay M Manning
- School of Medicine, Keele University, Keele, and Department of Medical Imaging, University of Exeter, Exeter, UK
| | - Faraz Mughal
- School of Medicine, Keele University, Keele; Centre for Mental Health and Safety, Division of Psychology and Mental Health, University of Manchester, Manchester; and honorary clinical research fellow, Warwick Medical School, Warwick, UK
| | | | | | | | - Zoe Paskins
- Keele University, Keele, and Haywood Academic Rheumatology Centre, Midlands Partnership Foundation Trust, Stoke-on-Trent, UK
| | - James A Prior
- School of Medicine, Keele University, Keele, and Haywood Academic Rheumatology Centre, Midlands Partnership Foundation Trust, Stoke-on-Trent, UK
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Sandbrink F, Murphy JL, Johansson M, Olson JL, Edens E, Clinton-Lont J, Sall J, Spevak C. 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. Ann Intern Med 2023; 176:388-397. [PMID: 36780654 DOI: 10.7326/m22-2917] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/15/2023] Open
Abstract
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.
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Affiliation(s)
- Friedhelm Sandbrink
- National Pain Management, Opioid Safety, and Prescription Drug Monitoring Program, Veterans Health Administration, Washington DC VA Medical Center, and Department of Neurology, George Washington University, Washington, DC (F.S.)
| | - Jennifer L Murphy
- Pain Management, Opioid Safety, and Prescription Drug Monitoring Program, Veterans Health Administration, Washington, DC (J.L.M.)
| | - Melanie Johansson
- Walter Reed National Military Medical Center, Bethesda, Maryland (M.J.)
| | | | - Ellen Edens
- Opioid Reassessment Clinic, Yale Addiction Psychiatry Service, National TeleMental Health Center, VA Connecticut Healthcare System, West Haven, Connecticut (E.E.)
| | | | - James Sall
- Evidence Based Practice, Quality and Patient Safety, Veterans Health Administration, Washington, DC (J.S.)
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Prior JA, Crawford-Manning F, Whittle R, Abdul-Sultan A, Chew-Graham CA, Muller S, Shepherd TA, Sumathipala A, Mallen CD, Paskins Z. Vertebral fracture as a risk factor for self-harm: a retrospective cohort study. BMC Musculoskelet Disord 2021; 22:757. [PMID: 34481480 PMCID: PMC8417993 DOI: 10.1186/s12891-021-04631-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 08/17/2021] [Indexed: 12/04/2022] Open
Abstract
Background The prevention of self-harm is an international public health priority. It is vital to identify at-risk populations, particularly as self-harm is a risk factor for suicide. This study aims to examine the risk of self-harm in people with vertebral fractures. Methods Retrospective cohort study. Patients with vertebral fracture were identified within the Clinical Practice Research Datalink and matched to patients without fracture by sex and age. Incident self-harm was defined by primary care record codes following vertebral fracture. Overall incidence rates (per 10,000 person-years (PY)) were reported. Cox regression analysis determined risk (hazard ratios (HR), 95 % confidence interval (CI)) of self-harm compared to the matched unexposed cohort. Initial crude analysis was subsequently adjusted and stratified by median age and sex. Results The number of cases of vertebral fracture was 16,293, with a matched unexposed cohort of the same size. Patients were predominantly female (70.1 %), median age was 76.3 years. Overall incidence of self-harm in the cohort with vertebral fracture was 12.2 (10.1, 14.8) /10,000 PY. There was an initial crude association between vertebral fracture and self-harm, which remained after adjustment (HR 2.4 (95 %CI 1.5, 3.6). Greatest risk of self-harm was found in those with vertebral fractures who were aged below 76.3 years (3.2(1.8, 5.7)) and male (3.9(1.8, 8.5)). Conclusions Primary care patients with vertebral fracture are at increased risk of self-harm compared to people without these fractures. Male patients aged below 76 years of age appear to be at greatest risk of self-harm. Clinicians need to be aware of the potential for self-harm in this patient group.
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Affiliation(s)
- James A Prior
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, ST5 5BG, Staffordshire, UK. .,Midlands Partnership NHS Foundation Trust, Stafford, UK.
| | - Fay Crawford-Manning
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, ST5 5BG, Staffordshire, UK.,Midlands Partnership NHS Foundation Trust, Stafford, UK
| | - Rebecca Whittle
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, ST5 5BG, Staffordshire, UK
| | - Alyshah Abdul-Sultan
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, ST5 5BG, Staffordshire, UK
| | - Carolyn A Chew-Graham
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, ST5 5BG, Staffordshire, UK.,Midlands Partnership NHS Foundation Trust, Stafford, UK
| | - Sara Muller
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, ST5 5BG, Staffordshire, UK
| | - Tom A Shepherd
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, ST5 5BG, Staffordshire, UK
| | - Athula Sumathipala
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, ST5 5BG, Staffordshire, UK.,Midlands Partnership NHS Foundation Trust, Stafford, UK
| | - Christian D Mallen
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, ST5 5BG, Staffordshire, UK
| | - Zoe Paskins
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, ST5 5BG, Staffordshire, UK.,Haywood Academic Rheumatology Centre, Midland Partnership NHS Foundation Trust, ST6 7AG, Stoke-on-Trent, UK
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Characteristics associated with later self-harm hospitalization and/or suicide: A follow-up study of the HUNT-2 cohort, Norway. J Affect Disord 2020; 276:369-379. [PMID: 32871667 DOI: 10.1016/j.jad.2020.03.163] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 02/20/2020] [Accepted: 03/29/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND To improve suicide and self-harm prevention in adults, better knowledge on preexisting characteristics and risk factors is of great importance. METHODS This is a population-based case-control study; baseline measures were collected in the second wave of the North-Trøndelag Health Study (HUNT-2, 1995-1997) in Norway, and outcomes were observed for up to 19 years. Average follow up time was 4.9 years for self-harm and 6.8 years for suicides. Out of 93,898 eligible adult inhabitants aged 20 and above, a total of 65,229 (70%) participated in the study. The data were linked to the National Mortality Registry and hospital patient records in the three hospitals covering the HUNT-2 catchment area. RESULTS Among the participants, 332 patients (68% women) were hospitalized because of self-harm (HSH), and 91 patients (32% women) were died by suicide (SU). A total of 10% of those who died by SU had previously been HSH. People in the HSH and SU groups were younger, reported more depression and anxiety symptoms, sleeping problems, higher use of alcohol and tobacco, poorer social network and more economic problems, compared to the rest of the HUNT-2 population. In addition, the HSH group reported more somatic health problems, higher use of health services, higher sick leave, and lower work participation than the SU group. LIMITATIONS Younger adults (20-40 years) were under-represented in HUNT-2. Younger adults (20-40 years) were constituted 31.7% in HUNT-2, 50% in HSH and 33% in SU. Further, we did not identify less severe self-harm, not requiring hospitalization. Life changes, adverse events, and other possible triggers to self-harming behavior were not recorded. CONCLUSION Psychological problems were long-term predictors of both HSH and SU. Somatic health problems and lower functional performance were more present in HSH-group compared to the SU-group.
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Prior JA, Paskins Z, Whittle R, Abdul-Sultan A, Chew-Graham CA, Muller S, Bajpai R, Shepherd TA, Sumathipala A, Mallen CD. Rheumatic Conditions as Risk Factors for Self-Harm: A Retrospective Cohort Study. Arthritis Care Res (Hoboken) 2020; 73:130-137. [PMID: 32526099 DOI: 10.1002/acr.24345] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 06/02/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To examine the risk of self-harm in rheumatic conditions. METHODS We conducted a retrospective cohort study using data from the Clinical Practice Research Datalink. Patients with ankylosing spondylitis, fibromyalgia, osteoarthritis, or rheumatoid arthritis were identified from 1990 to 2016 and matched to patients without these conditions. Incident self-harm was defined by medical record codes following a rheumatic diagnosis. Incidence rates (per 10,000 person-years) were reported for each condition, both overall and year-on-year (2000-2016). Cox regression analysis determined risk (hazard ratio [HR] and 95% confidence interval [95% CI]) of self-harm for each rheumatic cohort compared to the matched unexposed cohort. Initial crude analysis was subsequently adjusted and stratified by age and sex. Due to nonproportionality over time, osteoarthritis was also stratified by disease duration (<1 year, ≥1 to <5 years, ≥5 to <10 years, and ≥10 years). RESULTS The incidence of self-harm was highest in patients with fibromyalgia (HR 25.12 [95% CI 22.45-28.11] per 10,000 person-years) and lowest for osteoarthritis (HR 6.48 [95% CI 6.20-6.76]). There was a crude association with each rheumatic condition and self-harm, except for ankylosing spondylitis. Although attenuated, these associations remained after adjustment for fibromyalgia (HR 2.06 [95% CI 1.60-2.65]), rheumatoid arthritis (HR 1.59 [95% CI 1.20-2.11]), and osteoarthritis (1 to <5 years HR 1.12 [95% CI 1.01-1.24]; ≥5 to <10 years HR 1.35 [95% CI 1.18-1.54]). Age and sex were weak effect modifiers for these associations. CONCLUSION Primary care patients with fibromyalgia, osteoarthritis, or rheumatoid arthritis (but not ankylosing spondylitis) are at increased risk of self-harm compared to people without these rheumatic conditions. Clinicians need to be aware of the potential for self-harm in patients with rheumatic conditions (particularly fibromyalgia), explore mood and risk with them, and offer appropriate support and management.
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Affiliation(s)
- James A Prior
- Keele University, Newcastle, and Midlands Partnership NHS Foundation Trust, Stafford, UK
| | - Zoe Paskins
- Keele University, Newcastle, and Haywood Academic Rheumatology Centre, Midlands Partnership NHS Foundation Trust, Stoke-on-Trent, UK
| | | | | | - Carolyn A Chew-Graham
- Keele University, Newcastle, and Midlands Partnership NHS Foundation Trust, Stafford, UK
| | | | | | | | - Athula Sumathipala
- Keele University, Newcastle, and Midlands Partnership NHS Foundation Trust, Stafford, UK
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Rosenberg JM, Bilka BM, Wilson SM, Spevak C. Opioid Therapy for Chronic Pain: Overview of the 2017 US Department of Veterans Affairs and US Department of Defense Clinical Practice Guideline. PAIN MEDICINE 2019; 19:928-941. [PMID: 29025128 DOI: 10.1093/pm/pnx203] [Citation(s) in RCA: 81] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Description The US Department of Veterans Affairs (VA) and US Department of Defense (DoD) revised the 2010 clinical practice guideline (CPG) for the management of opioid therapy for chronic pain, considering the specific needs of the VA and DoD and new evidence regarding prescribing opioid medication for non-end-of-life-related chronic pain. This paper summarizes the major recommendations and compares them with the US Centers for Disease Control and Prevention (CDC) guideline for prescribing opioids. Patient Population This Opioid Therapy CPG was developed for VA-DoD service members, veterans, and their families. Methods The VA/DoD Evidence-Based Practice Work Group convened a VA/DoD guideline renewal development effort and conformed to the guidelines established by the VA/DoD Joint Executive Council (JEC) and VA/DoD Health Executive Council (HEC). The panel developed questions, searched and evaluated the literature, developed recommendations using GRADE methodology, and developed algorithms. Passage of the CARA Act by Congress compelled consideration and comparison with the CDC opioid therapy guideline mid-development. Results There were 18 recommendations made. This article focuses on guideline development and key recommendations with CDC comparisons taken from four major areas, including: initiation and continuation of opioids;type, dose, follow-up, and taper of opioids;risk mitigation;acute pain. Conclusions Guideline development and recommendations are presented. There was substantial overlap with the CDC opioid guideline. Additionally, there were items particularly relevant to the VA-DoD, including risk mitigation, suicide prevention, and preventing opioid use disorder in young patients. Our guideline highlights avoiding opioid therapy longer than 90 days as a critical juncture.
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Affiliation(s)
- Jack M Rosenberg
- Department of Veterans Affairs, Physical Medicine and Rehabilitation, Ann Arbor, Michigan
| | - Brandon M Bilka
- Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Sara M Wilson
- Walter Reed National Military Medical Center, Bethesda, Maryland, USA
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Relative toxicity of analgesics commonly used for intentional self-poisoning: A study of case fatality based on fatal and non-fatal overdoses. J Affect Disord 2019; 246:814-819. [PMID: 30634113 DOI: 10.1016/j.jad.2019.01.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 12/21/2018] [Accepted: 01/04/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Analgesics are used most frequently in fatal and non-fatal medicinal self-poisonings. Knowledge about their relative toxicity in overdose is important for clinicians and regulatory agencies. METHODS Using data for 2005-2012 we investigated case fatality (number of suicides relative to number of non-fatal self-poisonings) of paracetamol, aspirin, codeine, dihydrocodeine, tramadol, paracetamol with codeine (co-codamol), paracetamol with dihydrocodeine (co-dydramol), ibuprofen and co-proxamol (paracetamol plus dextropropoxyphene; withdrawn in the UK in 2008 due to high toxicity). Data on suicides obtained from the Office for National Statistics and on non-fatal self-poisonings from the Multicentre Study of Self-harm in England. Case fatality was estimated for each drug, using paracetamol as the reference category. RESULTS Compared to paracetamol and based on single drug deaths the case fatality index of dihydrocodeine was considerably elevated (odds ratio (OR) 12.81, 95% Confidence Interval (CI) 10.19-16.12). Case fatality indices for tramadol (OR 4.05, 95% CI 3.38-4.85) and codeine (OR 2.21, 95% CI 1.81-2.70) were also significantly higher than for paracetamol. The results when multiple drug deaths were included produced similar results. The relative toxicity of co-proxamol far exceeded that of the other analgesics. LIMITATIONS Data on fatal self-poisonings were based on national data, whereas those for non-fatal poisonings were based on local data. CONCLUSIONS Dihydrocodeine and tramadol are particularly toxic in overdose and codeine is also relatively toxic. They should be prescribed with caution, particularly to individuals at risk of self-harm.
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Calati R, Laglaoui Bakhiyi C, Artero S, Ilgen M, Courtet P. The impact of physical pain on suicidal thoughts and behaviors: Meta-analyses. J Psychiatr Res 2015; 71:16-32. [PMID: 26522868 DOI: 10.1016/j.jpsychires.2015.09.004] [Citation(s) in RCA: 124] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 08/11/2015] [Accepted: 09/10/2015] [Indexed: 11/25/2022]
Abstract
Although the relationship between physical pain and suicidal thoughts and behaviors has been explored in multiple epidemiologic and clinical studies, it is still far from being well understood. Consequently, we conducted a meta-analysis of studies comparing rates of suicidal thoughts and behaviors in individuals with and without physical pain. We searched MEDLINE and PsycINFO (May 2015) for studies comparing rates of current and lifetime suicidal thoughts and behaviors (death wish, suicide ideation, plan, attempt and death: DW, SI, SP, SA, SD) in individuals with any type of physical pain (headache, back, neck, chest, musculoskeletal, abdominal and pelvic pains, arthritis, fibromyalgia, medically unexplained pain, and other not specified pain) versus those without it. Data were analyzed with Cochrane Collaboration Review Manager Software (RevMan, version 5.3). We assessed the methodological quality of the studies with the STROBE statement. Of the 31 included studies, three focused on lifetime DW, twelve focused on current SI (six lifetime), six focused on current SP (two lifetime), nine focused on current SA (11 lifetime) and eight on SD. Individuals with physical pain were more likely to report lifetime DW (p = 0.0005), both current and lifetime SI (both p < 0.00001), SP (current: p = 0.0008; lifetime: p < 0.00001), and SA (current: p < 0.0001; lifetime: p < 0.00001). Moreover, they were more likely to report SD (p = 0.02). In all analyses, the between study heterogeneity was high. Moreover, the presence of publication bias has been detected in the main outcomes. Physical pain is a consistent risk factor for suicidal thoughts and behaviors. Further research is required to investigate the specific impact of: 1) chronic versus acute pain, 2) different types of pain (e.g., medically unexplained pain), and 3) risk factors for suicide in chronic pain patients.
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Affiliation(s)
- Raffaella Calati
- INSERM U1061, La Colombière Hospital, University of Montpellier UM1, Montpellier, France; Department of Psychiatric Emergency & Acute Care, Lapeyronie Hospital, CHU Montpellier, Montpellier, France; FondaMental Foundation, France.
| | - Camelia Laglaoui Bakhiyi
- INSERM U1061, La Colombière Hospital, University of Montpellier UM1, Montpellier, France; Department of Psychiatric Emergency & Acute Care, Lapeyronie Hospital, CHU Montpellier, Montpellier, France; Psychiatric Unit, CHU Casablanca, Hassan II University, Casablanca, Morocco
| | - Sylvaine Artero
- INSERM U1061, La Colombière Hospital, University of Montpellier UM1, Montpellier, France
| | - Mark Ilgen
- VA Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, Ann Arbor, MI, USA; University of Michigan Department of Psychiatry, Ann Arbor, MI, USA
| | - Philippe Courtet
- INSERM U1061, La Colombière Hospital, University of Montpellier UM1, Montpellier, France; Department of Psychiatric Emergency & Acute Care, Lapeyronie Hospital, CHU Montpellier, Montpellier, France; FondaMental Foundation, France
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Im JJ, Shachter RD, Oliva EM, Henderson PT, Paik MC, Trafton JA. Association of Care Practices with Suicide Attempts in US Veterans Prescribed Opioid Medications for Chronic Pain Management. J Gen Intern Med 2015; 30:979-91. [PMID: 25693651 PMCID: PMC4471010 DOI: 10.1007/s11606-015-3220-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Revised: 08/06/2014] [Accepted: 01/27/2015] [Indexed: 10/24/2022]
Abstract
IMPORTANCE Patients receiving opioid therapy are at elevated risk of attempting suicide. Guidelines recommend practices to mitigate risk, but it is not known whether these are effective. OBJECTIVE Our aim was to examine associations between the receipt of guideline-recommended care for opioid therapy and risk of suicide attempt. DESIGN, SETTING, AND PARTICIPANTS This was a retrospective analysis of administrative data for all Veteran patients prescribed any short-acting opioids on a chronic basis or any long-acting opioids from the Veterans Health Administration during fiscal year 2010. MAIN OUTCOMES AND MEASURES Multivariate, mixed-effects logistic regression analyses were conducted to define the associations between the risk of suicide attempt and receipt of guideline-recommended care at the individual level and rates of use of recommended care at the facility level, while accounting for patient risk factors. RESULTS At the individual level, having a mood disorder was highly associated with suicide attempts (odds ratios [ORs] = 3.5, 3.9; 95% confidence intervals [CIs] = 3.3-3.9, 3.3-4.6 for chronic short-acting and long-acting groups, respectively). At the facility level, patients on opioid therapy within the facilities ordering more drug screens were associated with decreased risk of suicide attempt (ORs = 0.2, 0.3; CIs = 0.1-0.3, 0.2-0.6 for chronic short-acting and long-acting groups, respectively). In addition, patients on long-acting opioid therapy within the facilities providing more follow-up after new prescriptions were associated with decreased risk of suicide attempt (OR = 0.2, CI = 0.0-0.7), and patients on long-acting opioid therapy within the facilities having higher sedative co-prescription rates were associated with increased risk of suicide attempt (OR = 20.3, CI = 1.1-382.2). CONCLUSIONS AND RELEVANCE Encouraging facilities to make more consistent use of drug screening, provide follow-up within 4 weeks for patients initiating new opioid prescriptions, and avoid sedative co-prescription in combination with long-acting opioids may help prevent suicide attempts. Some clinicians may selectively employ guideline-recommended practices with at-risk patients.
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Affiliation(s)
- Jinwoo J Im
- Center for Health Care Evaluation, Department of Veterans Affairs, Menlo Park, CA, USA,
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Fishbain DA, Lewis JE, Gao J. The pain suicidality association: a narrative review. PAIN MEDICINE 2014; 15:1835-49. [PMID: 24995953 DOI: 10.1111/pme.12463] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVES The objective of this narrative review was to examine recent evidence and, when necessary, past evidence on the association between pain and suicidality. DESIGN Fifty-eight research reports were found on this topic, which had not previously been reviewed. These reports were divided into groups by whether they addressed suicide ideation (SI), suicide attempts (SAs), or suicide completion (SC), and what population they represented (acute pain patients [APPs], chronic pain patients [CPPs], other than APPs/CPPs) and whether they controlled for relevant confounders. Information as to whether the results of these studies supported/did not support the association of pain and suicidality was abstracted. For each group of studies (above), a vote counting method was utilized to determine the overall percentage of studies supporting/not supporting the association of pain and suicidality. According to this percentage, the consistency of the data supporting this association was rated according to Agency for Healthcare Research and Quality guidelines. RESULTS The following groups of studies received an A consistency rating (consistent evidence from multiple studies): SI, SA, and SC for other than APPs/CPPs; and SI, SA, and SC for CPP prevalence greater than an appropriate control group. Also, a subgroup of the SI, SA, and SC studies for other than APPs/CPPs had controlled for behavioral issues (potential confounders). These three subgroups also received an A consistency rating. The 58 studies also identified a number of new predictor variables for SI, SA, and SC in CPPs. CONCLUSIONS These studies solidify the evidence for an association between pain and SI, SA, and SC in both CPPs and other than APPs/CPPs.
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Affiliation(s)
- David A Fishbain
- Department of Psychiatry, Miller School of Medicine, University of Miami, Miami, Florida, USA; Department of Neurological Surgery, Miller School of Medicine, University of Miami, Miami, Florida, USA; Department of Anesthesiology, Miller School of Medicine, University of Miami, Miami, Florida, USA; Department of Psychiatry, Miami VA Medical Center, Miami, Florida, USA; State Farm Insurance, Bloomington, Illinois, USA
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Suicide attempts in chronic pain patients. A register-based study. Scand J Pain 2014; 5:4-7. [DOI: 10.1016/j.sjpain.2013.09.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Accepted: 09/17/2013] [Indexed: 11/21/2022]
Abstract
Abstract
Background
There are several studies about the relationship between depression and chronic non-malignant pain. These studies have shown that up to 50% of chronic pain patients are suffering from depression.
It is, therefore, reasonable to expect that pain patients would also have an increased risk of suicidal behaviour. This problem is not well studied.
Since 1990 the Centre for Suicide Research, Odense, Denmark has registered all suicide attempts in patients residing in the Region of Funen, Denmark.
The Pain Clinic, Odense University Hospital receives patients with chronic pain from the entire Region of Southern Denmark.
Purpose
The purpose of the study has been:
To investigate, whether patients treated in the Pain Clinic during the period from 1 January 2004 to 31 December 2009 had an increased risk of suicide attempts compared with the background population.
Materials and methods
The Register for Suicide Attempts (RSA) is a product of the WHO research programme WHO/EURO Multicentre Study on Para suicide. The RSA is a longitudinal person-based register. It contains information about people who have been in contact with the health care system in the County of Funen as a result of a suicide attempt.
The Pain Clinic, Odense University Hospital receives patients with non-malignant chronic pain from the Region of Southern Denmark with 1,194,659 inhabitants. Data about age, sex, and time of treatment for patients treated in the Pain Clinic during the period were registered. Time and method of the suicide attempts were registered in the RSA. By registry linkages between the patient registers it was possible to calculate any excess risk of suicide attempts in chronic pain patients in the study period.
We used a cohort design and calculated incidence rates (IR) and incidence rate ratios (IRRs) for suicide attempts, based on data from RSA. Poisson Regression analyses were used for calculation of IR and IRR for suicide attempts.
Results
In the study period from 1 January 2004 to 31 December 2009 1871 patients residing in the Region of Funen in Denmark were referred to The Pain Clinic.
In the patient group 258 suicide attempts in 110 persons were registered. In all 6% of the patient group had attempted suicide.
An increased risk of suicide attempts was found in the pain population as the incidence rate ratio (IRR) was 3.76 95% CI (3.22; 4.40). No statistical significant differences between men and women were found.
Conclusion
In a chronic non-malignant pain population, referred to a pain clinic, the risk of suicide attempts was increased.
Implications
It is important to be aware of risk factors for suicidal behaviour, i.e. pain history, depression, anxiety, abuse problems, and social problems when caring for patients with chronic pain. More knowledge and training of the staff caring for chronic pain patients are needed to decrease the risk of suicidal behaviour.
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Sandman CA, Kemp AS, Mabini C, Pincus D, Magnusson M. The role of self-injury in the organisation of behaviour. JOURNAL OF INTELLECTUAL DISABILITY RESEARCH : JIDR 2012; 56:516-526. [PMID: 22452417 PMCID: PMC3323749 DOI: 10.1111/j.1365-2788.2012.01552.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
BACKGROUND Self-injuring acts are among the most dramatic behaviours exhibited by human beings. There is no known single cause and there is no universally agreed upon treatment. Sophisticated sequential and temporal analysis of behaviour has provided alternative descriptions of self-injury that provide new insights into its initiation and maintenance. METHOD Forty hours of observations for each of 32 participants were collected in a contiguous 2-week period. Twenty categories of behavioural and environmental events were recorded electronically that captured the precise time each observation occurred. Temporal behavioural/environmental patterns associated with self-injurious events were revealed with a method (t-patterns; THEME) for detecting non-linear, real-time patterns. RESULTS Results indicated that acts of self-injury contributed both to more patterns and to more complex patterns. Moreover, self-injury left its imprint on the organisation of behaviour even when counts of self-injury were expelled from the continuous record. CONCLUSIONS Behaviour of participants was organised in a more diverse array of patterns when self-injurious behaviour was present. Self-injuring acts may function as singular points, increasing coherence within self-organising patterns of behaviour.
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Affiliation(s)
- C A Sandman
- Department of Psychiatry and Human Behaviour, School of Medicine, University of California, Irvine, Orange, CA 92868, USA.
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Differences between younger and older adults in the structure of suicidal intent and its correlates. Am J Geriatr Psychiatry 2010; 18:839-47. [PMID: 20220600 DOI: 10.1097/jgp.0b013e3181d145b0] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To analyze differences in the variables associated with severity of suicidal intent and in the main factors associated with intent when comparing younger and older adults. DESIGN Observational, descriptive cross-sectional study. SETTING Four general hospitals in Madrid, Spain. PARTICIPANTS Eight hundred seventy suicide attempts by 793 subjects split into two groups: 18-54 year olds and subjects older than 55 years. MEASUREMENTS The authors tested the factorial latent structure of suicidal intent through multigroup confirmatory factor analysis for categorical outcomes and performed statistical tests of invariance across age groups using the DIFFTEST procedure. Then, they tested a multiple indicators-multiple causes (MIMIC) model including different covariates regressed on the latent factor "intent" and performed two separate MIMIC models for younger and older adults to test for differential patterns. RESULTS Older adults had higher suicidal intent than younger adults (z = 2.63, p = 0.009). The final model for the whole sample showed a relationship of intent with previous attempts, support, mood disorder, personality disorder, substance-related disorder, and schizophrenia and other psychotic disorders. The model showed an adequate fit (chi²[12] = 22.23, p = 0.035; comparative fit index = 0.986; Tucker-Lewis index = 0.980; root mean square error of approximation = 0.031; weighted root mean square residual = 0.727). All covariates had significant weights in the younger group, but in the older group, only previous attempts and mood disorders were significantly related to intent severity. CONCLUSIONS The pattern of variables associated with suicidal intent varies with age. Recognition, and treatment of geriatric depression may be the most effective measure to prevent suicidal behavior in older adults.
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Bakare MO, Omigbodun OO, Kuteyi OB, Meremikwu MM, Agomoh AO. Psychological complications of childhood chronic physical illness in Nigerian children and their mothers: the implication for developing pediatric liaison services. Child Adolesc Psychiatry Ment Health 2008; 2:34. [PMID: 19019212 PMCID: PMC2596085 DOI: 10.1186/1753-2000-2-34] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2008] [Accepted: 11/19/2008] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Pediatric liaison services attending to the psychological health needs of children with chronic physical illness are limited or virtually non-existent in Nigeria and most sub-Saharan African countries, and psychological problems complicate chronic physical illness in these children and their mothers. There exist needs to bring into focus the public health importance of developing liaison services to meet the psychological health needs of children who suffer from chronic physical illness in this environment. Sickle cell disease (SCD) and juvenile diabetes mellitus (JDM) are among the most common chronic physical health conditions in Nigerian children. This study compared the prevalence and pattern of emotional disorders and suicidal behavior among Nigerian children with SCD, JDM and a group of healthy children. Psychological distress in the mothers of these children that suffer chronic physical illness was also compared with psychological distress in mothers of healthy control children. METHODS Forty-five children aged 9 to 17 years were selected for each group of SCD, JDM and controls. The SCD and JDM groups were selected by consecutive clinic attendance and the healthy children who met the inclusion criteria were selected from neighboring schools. The Youth version of the Computerized Diagnostic Interview Schedule for Children, version IV (C- DISC- IV) was used to assess for diagnosis of emotional disorders in these children. Twelve-item General Health Questionnaire (GHQ - 12) was used to assess for psychological distress in mothers of these children and healthy control children. RESULTS Children with JDM were significantly more likely to experience DSM - IV emotional disorders than children with SCD and the healthy group (p = 0.005), while children with JDM and SCD were more likely to have 'intermediate diagnoses' of emotional disorders (p = 0.0024). Children with SCD and JDM had higher rates of suicidal ideation when compared to healthy control children and a higher prevalence of maternal psychological distress was found in their mothers when compared to the mothers of healthy children (p = 0.035). CONCLUSION The higher prevalence of emotional disorders and suicidal ideation among children with SCD and JDM points to a need for development of liaison services in pediatric facilities caring for children with chronic physical illness to ensure holistic approach to their care. The proposed liaison services would also be able to provide family support interventions that would address the psychological distress experienced by the mothers of these children.
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Affiliation(s)
- Muideen O Bakare
- Child and Adolescent Unit, Federal Neuro-Psychiatric Hospital, New Haven, Enugu, Enugu State, Nigeria
| | | | - Olugbenga B Kuteyi
- Child and Adolescent Unit, Federal Psychiatric Hospital, Calabar, Nigeria
| | - Martin M Meremikwu
- Department of Pediatrics, College of Medical Sciences, University of Calabar, Nigeria
| | - Ahamefule O Agomoh
- General/Forensic Psychiatry Unit, Federal Neuro-Psychiatric Hospital, New Haven, Enugu, Enugu State, Nigeria
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Wynn J, King TM, Gambello MJ, Waller DK, Hecht JT. Mortality in achondroplasia study: a 42-year follow-up. Am J Med Genet A 2008; 143A:2502-11. [PMID: 17879967 DOI: 10.1002/ajmg.a.31919] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Achondroplasia (ACH) is the most common dwarfing condition having a prevalence of 1/25,000 live births. An increase in overall mortality, age specific mortality up to age 34 years and heart disease-related mortality was first reported in a 1987 study of a large population of ACH individuals. Since this study, concern about premature death, particularly in young adults, has persisted in the ACH population. The present study was undertaken to follow-up the patterns of mortality in a more contemporaneous ACH population. The vital status of 718 ACH individuals from the original study and 75 new ACH individuals was determined through the search of two computerized mortality database. The results showed that the overall mortality and age-specific mortality at all ages remained significantly increased. Rates of death were similar across all 42 years of follow-up suggesting that higher death rates were still occurring in the contemporary ACH population. Accidental, neurological, and heart disease-related deaths were increased in adults. Heart disease-related mortality, between ages 25 and 35, was more than 10 times higher than the general population. Overall survival and the average life expectancy for this ACH population were decreased by 10 years. These results demonstrate that despite advances in the knowledge of the natural history of ACH and health care needs of this population, mortality remains significantly increased. The high rate of heart disease related deaths illustrates the need to identify risk factors in the ACH population and develop treatment interventions accordingly.
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Affiliation(s)
- Julia Wynn
- Department of Pediatrics, University of Texas Health Science Center at Houston, Texas 77030, USA
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Holmstrand C, Engström G, Träskman-Bendz L. Disentangling dysthymia from major depressive disorder in suicide attempters' suicidality, comorbidity and symptomatology. Nord J Psychiatry 2008; 62:25-31. [PMID: 18389422 DOI: 10.1080/08039480801960164] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Dysthymia and major depressive disorder (MDD) are both risk diagnoses for suicidal behaviour. The aim of the present study was to identify clinical differences between these disorders, with a special reference to dysthymia. We studied suicidal behaviour, comorbidity and psychiatric symptoms of inpatient suicide attempters with dysthymia and MDD. We used DSM III-R diagnostics, the Suicide Assessment Scale (SUAS) and the Comprehensive Psychopathological Rating Scale (CPRS), part of which is the Montgomery and Asberg Depression Rating Scale (MADRS). Suicide mortality, number of repeated suicide attempts, method of suicide attempt and comorbidity of Axis I did not differ between the groups. Dysthymia patients, however, suffered more than MDD patients from DSM-III-R Axis II diagnoses (above all cluster B). There was no significant difference in Axis III comorbidity. Total SUAS, CPRS and MADRS scores did not differ significantly between the groups. When studying separate SUAS and CPRS items in a multivariate analysis, the CPRS items "aches and pains", "increased speech flow", increased "agitation" and "less tendency to worrying over trifles" as well as young age remained independently associated with dysthymia. Dysthymia patients, who later committed suicide, more often reported increased "aches and pains" than those who did not commit suicide. In this small sample of suicide attempters, we conclude that dysthymia suicide attempters, more often than MDD patients, have a comorbidity with personality disorders, which combined with a picture of aches and pains, could be factors explaining their suicidality.
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Affiliation(s)
- Cecilia Holmstrand
- Department of Psychiatry, Clinical Sciences, University Hospital, Lund, Sweden.
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