Study Suggests Non-Cancer Pain Associated with Suicide

BACKGROUND:
Although a substantial proportion of the research on suicide has focused on the connection between psychiatric disorders and suicide, a small but growing body of literature suggests that chronic pain is associated with suicidal behaviors. In addition, the extent to which suicide is associated with specific pain conditions has received limited attention; therefore, more information is needed to identify the individual pain conditions that are associated with the greatest risk for suicide. This study evaluated associations between non-cancer, pain-related clinical diagnoses (arthritis, back pain, migraine, tension headache or headache symptom, psychogenic pain, neuropathy, fibromyalgia) and suicide. Using VA data, investigators identified a large national sample of Veterans (N=4,863,086) who used VA healthcare in FY05 and were alive at the start of FY06. Investigators then determined death from suicide for these Veterans from FY06 through FY08, controlling for covariates including age, demographics, co-occurring psychiatric diagnoses (substance use disorders, bipolar disorder, depression, anxiety, PTSD, and schizophrenia), and medical comorbidity. Overall, 47% of Veterans had no pain conditions, 33% had only one pain condition, and 20% had two or more pain conditions.

FINDINGS:

• After controlling for demographics, most clinical diagnoses of non-cancer pain conditions were associated with risk of suicide in this large national cohort of Veterans.
• After further controlling for co-occuring psychiatric conditions, the associations between pain conditions and suicide death were reduced; however, significant associations remained for back pain, migraine, and psychogenic pain.
• In Veterans with a pain condition who died by suicide (N=2,838), the two most common methods of suicide were firearms (68%) and poisoning (17%).
• There was no relationship between the number of pain conditions and suicide risk.
• The authors suggest that there is a need for increased awareness of suicide risk among Veterans with back pain, migraine, and psychogenic pain, which may not be fully explained by comorbid psychiatric diagnoses.

LIMITATIONS:

• Aspects of the VA patient population may have influenced the results. For example, Veterans may have greater access to firearms and lower-cost prescriptions, and these potential means of suicide could influence likelihood of suicide mortality.
• This study analyzed diagnoses as recorded within VA's National Patient Care Database, and these may differ from the specific information reported in provider notes.
• The extent to which pain conditions relate to suicide likely varies depending on the timing and severity of the pain condition, which could not be fully modeled in the study analyses.

AUTHOR/FUNDING INFORMATION:
This study was conducted for program planning and evaluation purposes, not for research, with input from VA senior mental health leadership. All authors, except Dr. Katz, are part of HSR&D's Center for Clinical Management Research and the VA Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), both in Ann Arbor, MI.

Ilgen M, Kleinberg F, Ignacio R, Bohnert A, Valenstein M, McCarthy J, Blow F, and Katz I. Non-Cancer Pain Conditions and Risk of Suicide. JAMA Psychiatry July 1, 2013;70(7):692-97.