Risk for five forms of suicidality in acute pain patients and chronic pain patients vs pain-free community controls

Workplace Injury Compensation and Mental Health and Self-Harm Outcomes: A Systematic Review

Workers' compensation systems aim to financially support injured workers. However, seeking compensation often leads to poorer physical and mental health outcomes. This review examines previous studies to investigate the relationship between workers' compensation and mental health and self-harm outcomes. A three-tiered search strategy across five databases identified studies that examined workers' compensation claims as an exposure or risk factor, with outcomes related to mental health, self-harm and suicidality. Nine full-text studies were included; however, heterogeneity limited generalizability. Most studies supported an association between pursuing compensation and poorer mental health and self-harm outcomes. Some studies attributed this to specific aspects of the system such as justice perception and navigation of the claims system. Findings suggest an association between workers' compensation and mental health or self-harm outcomes. Inconclusive findings highlight the need for further research. Understanding the psychiatric impacts of pursuing compensation is crucial to help formulate a more accessible compensation system.

The relationship between work disability and subsequent suicide or self-harm: A scoping review

Work disability occurs when an injury or illness limits the ability of a worker to participate in employment. While evidence suggests that people with work disability are at increased risk of suicide and intentional self-harm, this relationship has not been the subject of systematic review. This scoping review aims to assess and summarise the research literature regarding the relationship between work disability and subsequent suicide or intentional self-harm. Review protocol was published on the Open Science Foundation and is reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. Peer-reviewed studies published in English from 1st January 2000 were included if they reported suicide or self-harm outcomes in people aged 15 years or older with work disability. Studies were identified via systematic search of Medline, Scopus and Pubmed databases, via recommendation from topic experts, and citation searching of included articles. A narrative synthesis was undertaken. Literature search yielded 859 records of which 47 eligible studies were included, nine set in workers' compensation, 20 in sickness absence, 13 in disability pension systems, and five from mixed cohorts. Of 44 quantitative studies, 41 reported a positive relationship between work disability and suicidal behaviour. The relationship is observed consistently across nations, work disability income support systems and health conditions. Several factors elevate risk of suicidal behaviour, including presence of mental health conditions and longer work disability duration. There were few studies in some nations and no suicide prevention interventions. The risk of suicide and self-harm is elevated in people experiencing work disability. Further observational research is required to fill evidence gaps. This review suggests the need for governments, employers and those involved in the care of people with work disability to focus on identification and monitoring of those at greatest risk of suicidal behaviour, and suicide prevention.

Understanding correlates of suicidality among those with usual pain and discomfort: A Canadian nationally representative study

OBJECTIVE

Suicidality (ideation, plans, attempts) is elevated among those with chronic pain. However, population-based research is limited and studies primarily focus on mechanisms associated with increasing rather than decreasing risk. This study aimed to identify correlates associated with increased and decreased odds of suicidality among Canadians with usual pain/discomfort in a nationally representative sample.

METHODS

Cross-sectional data from the 2012 Canadian Community Health Survey-Mental Health supplement (CCHS-MH; N = 25,113) identified individuals with usual pain/discomfort (i.e., chronic pain; n = 5891). Multiple logistic regressions examined correlates that may increase (disability, activity limitations) and decrease (social support, positive mental health, spirituality) odds of suicidality among individuals endorsing usual pain/discomfort.

RESULTS

Among those endorsing usual pain/discomfort, between 7.1% (suicide attempt) to 21.0% (suicide ideation) endorsed suicidality, notably higher than those without (2.0% vs 9.6% for suicide attempt and ideation, respectively). Both greater social support and positive mental health were associated with decreased odds of suicide ideation and attempts (adjusted odds ratio (AOR) range = 0.94-0.97). Those whose pain prevented most activities had increased odds of suicide plans and attempts (AOR range = 1.72-1.94). Additionally, greater disability was associated with increased odds of suicide ideation (AOR = 1.01, 95% CI[1.01-1.02], p < .001). A multivariable model including all risk and protective correlates found only positive mental health as significantly associated with decreased odds of suicide ideation and attempts.

CONCLUSIONS

These findings may inform targeted screening, prevention, and intervention strategies to promote resilience and mitigate risk, among those with usual pain/discomfort.

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.

Epidemiology of pain and relation to psychiatric disorders

Chronic pain is a common pain condition. Some psychiatric disorders, such as anxiety and depression, are also common in the general population. Epidemiological studies found that some psychiatric disorders are more commonly found among persons with chronic pain (e.g., headache, back pain) than those without chronic pain. Why those psychiatric disorders co-occur with chronic pain, however, is not well understood. Further, studies demonstrated that some psychiatric disorders, such as depression, increase the risk of chronic pain as well as its persistence. It is also recognized that chronic pain has a negative impact on the persistence of psychiatric disorders. The observations from clinical studies suggest that chronic pain is not a common comorbidity among individuals with other psychiatric disorders, such as dementia and schizophrenia. It is not clear if this is a consequence of any specific biological mechanism, or methodology problems in the studies. This paper provides an overview on the distribution of chronic pain and psychiatric disorders, followed by a review of studies that have demonstrated the association between psychiatric disorders and chronic pain.

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.

Perceived burdensomeness, thwarted belongingness and suicidal ideation in patients with fibromyalgia and healthy subjects: a cross-sectional study

Perceived burdensomeness and thwarted belongingness are key factors in the development of suicidal behaviors that have been frequently observed among patients with fibromyalgia. The aim of the present study was to compare these two factors in patients with fibromyalgia with and without suicidal ideation and healthy subjects. Secondary objectives were to evaluate the relationship between these two factors and the secondary variables included in the study, such as depression, sleep quality or the degree of marital adjustment. Perceived burdensomeness and thwarted belongingness were assessed with the Interpersonal Needs Questionnaire, depression and suicidal ideation with the Patients Health Questionnaire-9, suicidal risk with the Plutchik Suicide Risk scale, sleep with the Insomnia Severity Index, and marital adjustment with the Locke-Wallace Marital Adjustment scale. Questionnaire scores were compared with the Kruskal-Wallis test. 49 healthy subjects, 38 patients with fibromyalgia without suicidal ideation and 15 patients with fibromyalgia and suicidal ideations were included. Perceived burdensomeness scores were significantly higher in patients with suicidal ideation than in patients without suicidal ideation and controls; thwarted belongingness scores were significantly higher in patients with suicidal ideation than in controls. Marital adjustment was also significantly poor in patients with suicidal ideation than in patients without suicidal ideation and controls. Among patients with fibromyalgia, perceived burdensomeness seems to be strongly related with suicidal ideation, whereas thwarted belongingness seems to play a less relevant role at this respect. Poor marital adjustment could be related with depression.

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.

Association Between Lifetime Headache and History of Suicide Attempts in the Elderly

Background

Pain-related conditions have been reported to play a key role among risk factors for suicide. Headache in particular has been repeatedly associated with suicidal thoughts and behaviors. The aims of this study were: 1) to assess the association between lifetime headache (both non-migrainous headache and migraine) and lifetime suicide attempts (SA); 2) to differentiate, within subjects with lifetime SA, patients with and without lifetime headache in terms of socio-demographic and clinical features.

Methods

We studied 1965 subjects from a cohort of community-dwelling persons aged 65 years and over without dementia (the ESPRIT study), divided in two groups: those with (n = 75), and those without a lifetime SA (n = 1890). Logistic regression analyses were used to compare these groups according to lifetime headache status.

Results

After adjusting for gender, living alone, tobacco and alcohol consumption, and depressive, manic/hypomanic and anxiety disorders, lifetime headache frequency was significantly higher in subjects with a lifetime SA compared with controls (OR = 1.92 [1.17–3.15]). Additionally, different factors were identified as being associated with lifetime SA in participants with lifetime headache (female gender, a lower level of high-density lipoprotein cholesterol, insomnia, lifetime major depression) versus participants without headache (glycemia and lifetime major depression).

Conclusions

Lifetime headache was associated with lifetime SA. Subjects who are women and report the co-occurrence of headache and insomnia as well as lifetime major depression require higher attention and a careful screening for suicidal thoughts and behaviors.

Opioid dose and risk of suicide

Chronic pain is associated with increased risk of suicide, and opioids are commonly used to treat moderate to severe pain. However, the association between opioid dose and suicide mortality has not been examined closely. This retrospective data analysis described the risk of suicide associated with differing prescribed opioid doses. Data were from Veterans Affairs health care system treatment records and the National Death Index. Records analyzed were those of Veterans Affairs patients with chronic pain receiving opioids in fiscal years 2004 to 2005 (N = 123,946). Primary predictors were maximum prescribed morphine-equivalent daily opioid dose and opioid fill type. The main outcome measured was suicide death, by any mechanism, and intentional overdose death during 2004 to 2009. Controlling for demographic and clinical characteristics, higher prescribed opioid doses were associated with elevated suicide risk. Compared with those receiving ≤20 milligrams/day (mg/d), hazard ratios were 1.48 (95% confidence intervals [CI], 1.25-1.75) for 20 to <50 mg/d, 1.69 (95% CI, 1.33-2.14) for 50 to <100 mg/d, and 2.15 (95% CI, 1.64-2.81) for 100+ mg/d. The magnitude of association between opioid dose and suicide by intentional overdose was not substantially different from that observed for the overall measure of suicide mortality. Risk of suicide mortality was greater among individuals receiving higher doses of opioids, and treatment providers may want to view high opioid dose as a marker of elevated risk for suicide. Additional research is needed on opioid use, pain treatment, and suicide.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The impact of physical pain on suicidal thoughts and behaviors: Meta-analyses

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.

The risk of suicide mortality in chronic pain patients

Chronic pain has long been considered an important risk factor for suicidal behavior. Less well understood are the factors associated with the increased risk for suicide death within chronic pain populations. The purpose of this review is to examine recent research with regard to rates of and risk factors for suicide mortality in patients with chronic musculoskeletal pain. We conclude that patients with a number of chronic pain states are at increased risk for suicide death, and that this risk appears to be due, at least in part, to other well-known correlates of pain such as depression and substance use disorders. However, in all likelihood, there are aspects of chronic pain itself that add uniquely to an individual's suicide risk profile. Lastly, we address a theoretical perspective and offer recommendations for clinical practice.

Change in suicidal ideation after interdisciplinary treatment of chronic pain

OBJECTIVES

To examine suicidal ideation (SI) in individuals with chronic pain, especially change in suicidal thinking after interdisciplinary treatment.

MATERIALS AND METHODS

Consecutive patients (n=250) admitted to a 4-week, group-based chronic pain management program completed measures of pain intensity, functional limitations, depressive symptoms, overall distress, pain catastrophizing, self-perceived burden, and SI at pretreatment and posttreatment.

RESULTS

Before treatment, 30 (12.0%) participants were classified as having a high level of SI, 56 (22.4%) had a low level of SI, and 164 (65.6%) reported none. After treatment, there was a significant reduction in SI and improvements in all other outcomes, but there were still some individuals with high (n=22, 8.8%) or low (n=28, 11.2%) levels at discharge. Patients with high SI at baseline differed from those with no suicidal thinking on pretreatment and posttreatment measures of depression, distress, catastrophizing, and self-perceived burden, but not on pain intensity or functional limitations. Patients high in SI endorsed greater pain catastrophizing and self-perceived burden than those low in suicidal thinking. Sustained SI after treatment was associated with higher baseline levels of suicidal thinking and self-perceived burden to others, as well as a more limited overall response to treatment.

DISCUSSION

SI was common in individuals with chronic pain, although mostly at a low level. Interdisciplinary treatment may result in reduced suicidal thinking; however, some patients continue to express thoughts of self-harm. Future studies could examine processes of change and interventions for treatment-resistant suicidal concerns.

The pain suicidality association: a narrative review

OBJECTIVES

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

DESIGN

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

RESULTS

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

CONCLUSIONS

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

Exploring the Relationship of Three Medical Entitlement Beliefs and Psychiatric/Psychological Variables for Acute and Chronic Pain Patients

OBJECTIVES

The belief in medical care entitlement has recently resulted in major changes in the medical system in the United States. The objectives of this study were the following: to compare endorsement of three medical entitlement beliefs (I deserve the best medical care no matter what the cost [BMC], I am entitled to all of the medical care I want at no charge [NC], I shouldn't have to wait to see my doctors [W]) in community nonpatients without pain (CNPWP), acute pain patients (APPs), and chronic pain patients (CPPs) and to develop predictor models for these beliefs in APPs and CPPs.

DESIGN

CNPWP, APPs, and CPPs were compared statistically for frequency of endorsement of each belief. All available variables were utilized in logistic regression models to predict each belief in APPs and CPPs. Those affirming/nonaffirming each belief were compared by t-test for affirmation of narcissism, dependency, and antisocial practices on three scales from established inventories.

RESULTS

CPPs were significantly more likely than APPs to endorse BMC. No other comparisons were significant. The logistic regression models identified variables that related to narcissism, anger, doctor dissatisfaction, depression, and anxiety, which entered the models for both APPs and CPPs for some beliefs. Those APPs and CPPs who affirmed the beliefs of NC and W were more likely than their counterparts to affirm antisocial practices, but not narcissism or dependency.

CONCLUSIONS

Patient medical entitlement beliefs may be related to some psychiatric/psychological issues.

Chronic pain and the interpersonal theory of suicide

OBJECTIVE

Chronic pain is a known risk factor for suicide. To date, however, few studies of people with chronic pain have tested specific predictions about suicidal ideation that are derived from theory. The interpersonal theory of suicide proposes that the psychological constructs of thwarted belongingness and perceived burdensomeness are unique and independent precursors to suicidal ideation. We tested this hypothesis in a clinical sample of patients with chronic pain.

METHOD

A total of 303 patients of a chronic pain rehabilitation program completed measures of pain severity, duration, and disability; cognitive-affective measures of depression and catastrophizing; and interpersonal measures of relationship distress and self-perceived burden to others. The latter measures were included as indices of the belongingness and burdensomeness constructs. Participants also rated two items pertaining to suicidal ideation.

RESULTS

In a multiple regression analysis, both distress in interpersonal relations (β = 0.12, p = .037) and self-perceived burden to others (β = 0.25, p < .001) were significant predictors of suicidal ideation, even after adjusting statistically for demographic characteristics, pain severity and duration, functional limitations, catastrophizing, and depression.

CONCLUSIONS

These findings suggest that the interpersonal theory is relevant to understanding elevated rates of suicidal ideation among people with chronic pain, and may have broader applicability to other populations with chronic illness or disability.

The prevalence of smokers within chronic pain patients and highest pain levels versus comparison groups

OBJECTIVES.: The objectives of this study were to (1) compare the prevalence of smoking within chronic pain patients (CPPs) to community non-patients without pain (CNPWP), community patients with pain (CPWP), and acute pain patients (APPs); and (2) compare smokers to nonsmokers within CPPs, APPs, and CPWP for highest pain level. DESIGN.: CNPWP, CPWP, APPs, and CPPs were compared to each other for smoking status (nonsmoker, less than one pack per day, one pack/day or more, any amount per day). Within CPWP, APPs, and CPPs, smokers were also compared to nonsmokers by t-test for highest reported pain level. For both analyses, sub-analyses were performed controlling for age or gender, or race or education. RESULTS.: Utilizing all available patients, the prevalence of smokers within CPPs was significantly greater vs each of the comparison groups (CNPWP, CPWP, APPs). In the sub-analyses, only CPPs who were 38 or younger or male or White, or had some college or above were at greater risk than CPWP for smoking one pack or greater per day. CPP smokers were not significantly more likely than nonsmokers to have higher pain, and this was confirmed in the sub-analyses. CONCLUSIONS.: The prevalence of smokers could be significantly greater within CPPs vs CPWP. CPPs who smoke do not have higher levels of pain than nonsmoking CPPs.

Non-specific, functional, and somatoform bodily complaints

BACKGROUND

4-10% of the general population and 20% of primary care patients have what are called "non-specific, functional, and somatoform bodily complaints." These often take a chronic course, markedly impair the sufferers' quality of life, and give rise to high costs. They can be made worse by inappropriate behavior on the physician's part.

METHODS

The new S3 guideline was formulated by representatives of 29 medical and psychological specialty societies and one patient representative. They analyzed more than 4000 publications retrieved by a systematic literature search and held two online Delphi rounds and three consensus conferences.

RESULTS

Because of the breadth of the topic, the available evidence varied in quality depending on the particular subject addressed and was often only of moderate quality. A strong consensus was reached on most subjects. In the new guideline, it is recommended that physicians should establish a therapeutic alliance with the patient, adopt a symptom/coping-oriented attitude, and avoid stigmatizing comments. A biopsychosocial diagnostic evaluation, combined with sensitive discussion of signs of psychosocial stress, enables the early recognition of problems of this type, as well as of comorbid conditions, while lowering the risk of iatrogenic somatization. For mild, uncomplicated courses, the establishment of a biopsychosocial explanatory model and physical/social activation are recommended. More severe, complicated courses call for collaborative, coordinated management, including regular appointments (as opposed to ad-hoc appointments whenever the patient feels worse), graded activation, and psychotherapy; the latter may involve cognitive behavioral therapy or a psychodynamic-interpersonal or hypnotherapeutic/imaginative approach. The comprehensive treatment plan may be multimodal, potentially including body-oriented/non-verbal therapies, relaxation training, and time-limited pharmacotherapy.

CONCLUSION

A thorough, simultaneous biopsychosocial diagnostic assessment enables the early recognition of non-specific, functional, and somatoform bodily complaints. The appropriate treatment depends on the severity of the condition. Effective treatment requires the patient's active cooperation and the collaboration of all treating health professionals under the overall management of the patient's primary-care physician.

Exploration of the relationship between disability perception, preference for death over disability, and suicidality in patients with acute and chronic pain

HYPOTHESIS

Passive, active, and historical suicidality are associated with preference for death over disability.

DESIGN

Community nonpatients without pain, community patients with pain, and patients with acute and chronic pain were compared for endorsement of disability perception and preference for death over disability. Phi correlations and chi-square analyses were calculated between preference for death over disability and six suicidality items representing passive, active, and historical suicidality. Logistic regression was used to predict preference for death over disability in patients with acute and chronic pain.

RESULTS

For patients with acute and chronic pain, endorsement of preference for death over disability correlated significantly with all six suicidality items. The logistic regression models identified the following variables as predictors for preference for death over disability in patients with acute pain: the Behavior Health Inventory (BHI 2) family dysfunction scale, history of wanting to die, and disability perception. For patients with chronic pain, predictors were the BHI 2 Borderline scale, history of wanting to die, treated fairly by family item, frequent suicide ideation, people I trust turn on me item, and disability perception. Preference for death over disability was a statistically significant predictor in patients with chronic pain for disability perception, recent suicide ideation, having a suicidal plan, and a history of wanting to die but was not a significant predictor for any suicide items in patients with acute pain.

CONCLUSION

Preference for death over disability is associated with passive and active suicide ideation and historical suicidality in patients with chronic pain.

Addressing both depression and pain in late life: the methodology of the ADAPT study

OBJECTIVE

To describe the methodology of the first NIH-funded clinical trial for seniors with comorbid depression and chronic low back pain.

METHODS

Randomized controlled effectiveness trial using stepped care methodology. Participants are ≥60 years old. Phase 1 (6 weeks) is open treatment with venlafaxine xr 150 mg/day and supportive management (SM). Response is 2 weeks of PHQ-9 ≤5 and at least 30% improvement in the average numeric rating scale for pain. Nonresponders progress to phase 2 (14 weeks) in which they are randomized to high-dose venlafaxine xr (up to 300 mg/day) with problem solving therapy for depression and pain (PST-DP) or high-dose venlafaxine xr and continued SM. Primary outcomes are the univariate pain and depression response and both observed and self-reported disability. Survival analytic techniques will be used, and the clinical effect size will be estimated with the number needed to treat. We hypothesize that self-efficacy for pain management will mediate response for subjects randomized to venlafaxine xr and PST-DP.

RESULTS

Not applicable.

CONCLUSIONS

The results of this trial will inform the care of these complex patients and further understanding of comorbid pain and depression in late life.

Suicide among persons with back pain: a population-based study of 2310 suicide victims in Northern Finland

STUDY DESIGN

A population-based study of suicides and linkage with national hospital discharge registers.

OBJECTIVE

To investigate the prevalence of hospital-treated musculoskeletal diseases, particularly back pain (BP), among suicide victims to compare suicide characteristics between victims with and without musculoskeletal diseases, to analyze comorbidity between musculoskeletal diseases and psychiatric disorders, and to evaluate whether specific drugs have a role in suicides by poisoning.

SUMMARY OF BACKGROUND DATA

Depression, other psychiatric disorders, and suicidal behavior are common comorbid conditions in patients with diseases of the musculoskeletal system.

METHODS

The data consisted of 2310 suicides (1885 men and 425 women) committed in the province of Oulu in Northern Finland during 1988 to 2007. The information on hospital-treated musculoskeletal diseases (MSD) was extracted from the Finnish Hospital Discharge Registers. The suicide victims with a diagnosis of BP, including sciatica (BP, n = 133), and victims with MSD other than BP/MSD, n = 357) were compared with those of having no history of MSD (reference group, n = 1820). The data on suicides were based on death certificates that were taken from official medicolegal investigations.

RESULTS

A total of 490 (21.3%) of suicide victims had a history of hospital-treated MSD. The age of death of the victims with BP was about 11 years higher compared with the reference group. After adjusting for age, nonviolent suicide methods and use of analgesics in poisoning suicides in both genders and hospital-treated depression/substance-related disorders in men were also more common in the BP and MSD groups. Women with BP had been more often under the influence of alcohol when committing suicide compared with the other groups.

CONCLUSION

Victims with a history of hospital-treated MSD committed suicide at older age. However, the older the person is, the more is the chance that he or she needs to have a treatment for some MSD at some point of life. Use of analgesics as a potential suicide method should be kept in mind when treating patients with musculoskeletal system diseases.

Severe pain predicts greater likelihood of subsequent suicide

Using data from the 1999 Large Health Survey of Veterans, Veterans Affairs' medical records, and the National Death Index (N = 260,254), the association between self-reported pain severity and suicide among veterans as examined, after accounting for demographic variables and psychiatric diagnoses. A Cox proportional hazards regression demonstrated that veterans with severe pain were more likely to die by suicide than patients experiencing none, mild, or moderate pain (HR: 1.33; 95% CI: 1.15, 1.54), after controlling for demographic and psychiatric characteristics. These results indicate that pain evaluations should be included in comprehensive suicide assessments and suicide prevention efforts.

Association between substance use disorder status and pain-related function following 12 months of treatment in primary care patients with musculoskeletal pain

The goal of this study was to examine relationships between substance use disorder (SUD) history and 12-month outcomes among primary care patients with chronic noncancer pain (CNCP). Patients were enrolled in a randomized trial of collaborative care intervention (CCI) versus treatment as usual (TAU) to improve pain-related physical and emotional function. At baseline, 72 of 362 patients (20.0%) had a history of SUD. Compared to CNCP patients without SUD, those with comorbid SUD had poorer pain-related function and were more likely to meet criteria for current major depression and posttraumatic stress disorder (all P values <.05). Logistic regression analyses were conducted to examine whether SUD status was associated with clinically significant change over 12 months in pain-related function (30% reduction in Roland Morris Disability Questionnaire Score). The overall model was not significant in the CCI group. However, within the TAU group, participants with a SUD history were significantly less likely to show improvements in pain-related function (OR = .30, 95% CI = .11-.82). CNCP patients with comorbid SUD reported greater functional impairment at baseline. Patients with SUD who received usual care were 70% less likely to have clinically significant improvements in pain-related function 12 months postbaseline, and SUD status did not impede improvement for the CCI group.

PERSPECTIVE

Chronic noncancer pain patients with a history of a substance use disorder (SUD) report poorer pain-related functioning and are less likely to experience clinically significant improvements from usual pain treatment. Providers should assess for SUD status and provide more intensive interventions for these patients.