Chronic Pain and Suicide

This article broaches a delicate but necessary topic: how chronic pain can increase the chances of suicidal thoughts and actions. Please read with care if you are vulnerable.


Chronic pain can lead to suicidal thoughts and even suicidal actions. With chronic pain affecting a high percentage of the population, this is a rising problem that must be addressed. Leaving this issue unchecked is literally fatal. This study on the subject states that, “individuals with chronic pain are at least twice as likely to report suicidal behaviours or to complete suicide”.

If you’re currently contemplating suicide, stop – pick up the phone and call one of the many suicide crisis lines. There are people waiting, ready to help.

There are many risk factors which contribute to the high numbers of suicidal pain patients. Interestingly, the severity of pain is not one of the main risk factors, but rather how patients perceive and experience their pain. This study concluded that “pain characteristics (e.g. type, duration, and intensity/severity) and physical status (e.g. pain interference or disability) were not related to suicide risk.” So, if the severity of pain doesn’t correlate with suicide in pain patients, what makes us more vulnerable? Let’s take a look.

Comorbid mental illness

Chronic pain can have a big impact on mental health. Many chronic illnesses list anxiety and depression as part of their symptoms. The pain itself combined with fatigue and the loss of functioning that often comes with chronic pain, especially when left untreated, can contribute to depression. This study on suicidality in female patients with fibromyalgia found that “Depression was the factor most strongly associated with both suicidal ideation and the risk of suicide.”

Hypervigilance (being overly focused on pain levels), catastrophizing (worrying excessively about your pain) and fear avoidance (becoming fearful of worsening your pain leading to avoidance of activity) can all contribute to anxiety and depression. Our body and mind are connected and influence one another. When we are struggling with a mental illness, it can worsen our pain and associated symptoms.

Often chronic pain patients don’t seek psychiatric help when they’re struggling mentally, because they are worried that their physical symptoms will be invalidated as mentioned here. They fear that yet more stigma will lead to them being told that their pain is ‘all in their head’.

Chronic pain patients can be at risk for suicide with or without comorbid mental illness however, as this study found. The other factors we will discuss can contribute to mental illness, but can also contribute to patients without a mental illness feeling suicidal.

Reduced quality of life

How patients perceive their pain can have a big impact on how they cope with it mentally, and how they actively manage their pain. When patient’s feel powerless and hopeless against their pain, they are less likely to engage in adaptive (meaning helpful) coping behaviors.

This negative perception of pain can reduce the quality of life and lead to chronic pain taking over. This is not the patient’s fault; it’s completely understandable. For the majority, we are not told by medical professionals that chronic pain can get better, or that we can live well despite our chronic pain. We are not all given the tools or treatment to regain functioning and improve our quality of life.

The following factors can contribute to reduced quality of life:

  • Reduced levels of functioning

When chronic pain is left untreated, often patient’s experience reduced levels of functioning. They may not be able to keep up with daily tasks or engage in hobbies and activities which used to make them happy. This can lead to the feeling of chronic pain having taken your independence and sapped the joy out of your life.

Often with reduced functioning comes needing to ask loved ones for help. This can be a big knock to your confidence and can be incredibly frustrating to not be able to do things for yourself. It’s common for patients to feel guilty and often like a burden on their loved ones as they take on a more caring role. Understandably, this is taxing emotionally and can contribute to patients feeling they don’t want to continue living like this.

This study focused on this sense of feeling like a burden to family and friends as a risk factor for suicidal ideation (SI), and concluded that, “perceived burdensomeness was the sole predictor of SI, even in the presence of other well‐established risk factors”

  • Loss of social connections

Humans are fundamentally social creatures. We need social connections to thrive, to feel part of the world around us. Chronic pain can often lead to us not being able to keep up with social activities due to our symptoms. Fear avoidance can mean that patients often withdraw from getting out socially because they fear it may worsen their pain.

Due to feeling unable to socialize, many chronic pain patients feel that they are alone in their pain. Often, they don’t have connections with others who share their condition. Due to most chronic pain symptoms being invisible, often loved ones don’t understand what they are going through and this can enhance the patient’s feelings of being alone. This loss of social connections can lead to social isolation and a feeling of deep-set loneliness. Loneliness is one of the biggest risk factors for suicide as this study explains.

  • Financial worries

With reduced functioning, patients are often unable to go out to work. Many chronic pain patients are unemployed, meaning they struggle financially. Medical bills can contribute to debt and financial worries. This can be extremely stressful, contributing to the pain and stress cycle. Feeling that you are drowning in debt and not seeing a way out can be overwhelming.

  • Confused sense of self

Many people with chronic pain lose sight of who they are as a person. When you can’t engage in the activities you used to enjoy, when you can’t work and feel you’ve lost your independence, it can make you question who you are. It’s common to feel that you are in conflict with your body, angry at it because it’s betraying and letting you down. It can feel as though you are not the same person you were before you became chronically ill. This confused sense of identity can make patients feel detached from the world around them, unsure about their purpose in life or how to move forward.

The concept of chronic pain ‘being forever’

When you are diagnosed with chronic pain, it’s common to be told that there’s not much medical professionals can do. Many are sent away without a diagnosis due to stigma. Those who are diagnosed are rarely referred for appropriate treatment. Many are told that they will need to ‘learn to live with’ their chronic pain.

This was my experience. When I was diagnosed with fibromyalgia, I was never given any indication that it was treatable. I was never offered psychological therapies or any kind of effective treatment. I regularly went away from the specialist’s office under the impression that this was just going to be my life now, and that I would have to try and get on with things as they were. Until I started to do my own research, I had no idea that my symptoms could improve, that I could get back to work and to the activities that I enjoy, and that I could live a full life!

When you feel that chronic pain is forever, the future can seem daunting. You start to wonder if you can set goals for the future if you’ll ever be able to function and enjoy your life. It truly can feel hopeless, and this can pose a big risk for suicidal feelings. This study found that if patients had hope for a cure or their symptoms improving, it would protect against suicidal ideation.

The fact that there are treatments out there that can help people to get their lives back, but people are not made aware of them is simply not good enough. Nobody deserves to be left to feel that they have no hope, when there are scientifically proven, easily accessible, cost effective options available!

The desire to escape from pain

Being in constant pain is a horrible experience. Knowing that this pain is long term and for some people constant, can make it feel impossible to go on. It’s completely natural not to want to live in pain. Your body and mind are not designed to cope with being in pain regularly. When patients are not given another way to escape from their pain (meaning through treatment), they can feel that there is only one escape route.

Self-stigma

Often the stigma we impose upon ourselves can be just as bad as, if not worse than, the stigma we face from society and medical professionals regarding our chronic pain. Needing to ask for help and feeling ‘weak’ can have a big impact on confidence levels. Many people impose self-stigma upon themselves, feeling that they are not keeping with the stereotypical role of what a man or woman ‘should do’ within the home or family setting.

Pain catastrophizing

Catastrophizing about your pain, whether you have a comorbid mental illness or not, can put you at high risk for suicidal thoughts and behaviours. Catastrophizing about your pain means that you are worrying about it excessively, anticipating and fearing your pain worsening in situations that haven’t even happened yet. Patients who catastrophize often worry about the impact of their chronic pain on their future, and this can spiral out of control.

When patients are catastrophizing, their stress levels are extremely high which takes a toll on both the body and mind. Catastrophizing can result in more pain and reduced quality of life, contributing to suicide risk. Catastrophizing can also increase insomnia (another suicide risk factor) in patients because it’s hard to sleep when your mind is worrying in overdrive.

High stress levels

We already know that chronic pain causes high stress levels for so many reasons and that stress increases pain. High stress levels also pose one of the highest risks for suicide, even in those without chronic pain as this study found.

Our body and mind are not designed to be in a prolonged state of stress. Stress can impact our ability to think clearly, lower our quality of life, make it tough to concentrate and to solve problems. This study explains that as chronic pain patients, we are more “extremely vulnerable to stressors”, even if our pain is well-managed.

Access to strong medications

Many pain patients are offered strong painkillers and anti-inflammatories, such as opioids. When you combine the risk for suicidal ideation with access to medications that are strong enough to easily be taken at a fatal dose, the risk for suicide increases exponentially. This study states that “access to opioids, and specifically to large quantities of opioids, could increase the risk of suicide in those with chronic pain.”

The study also explains that opioids are markers for an increased risk of suicide in another way. When an increased dose of opioids is prescribed, it’s because a patient’s symptoms are severe and are not improving. This indicates that patients are not receiving appropriate treatment and that they are struggling, which correlates with the other risk factors we have discussed.

Substance abuse

A lot of chronic pain patients who are left untreated and who have their pain invalidated by doctors turn to alcohol or illicit drugs to try and cope mentally and physically with their pain. This can lead to addiction, another high-risk factor for suicide.

Substance abuse, especially when it is long term, can have devastating effects not only on the patient’s mind and body but also on their lives. This without doubt can increase the risk of suicide. This study explains aptly how our judgement is changed under the influence of many substances, explaining that, “many substances reduce inhibition and enhance impulsivity, and suicide may be viewed in some contexts as an impulsive act “

Cognitive issues

Many chronic illnesses come with cognitive difficulties. Patients can have problems with memory and problem solving, as well as experiencing general confusion. Living with fibromyalgia, I struggle with fibro fog, which can make it hard to think clearly when it’s at its worst.

Depression and anxiety can also cloud your judgement and reduce problem solving skills. When patients aren’t able to think straight and can struggle to solve problems, it can put them at risk for turning to suicide as an option as this study explains.

Insomnia

Lack of sleep is one of the highest risk factors for suicide in any person, even out with chronic pain. When we don’t get enough rest, our bodies and minds struggle to function. Tiredness can make your mood drop as well as causing you to feel weepy and confused. Fatigue can cloud your judgement and make you act out of character.

For many chronic pain patients, sleep is the only respite they get from their symptoms. When they are deprived of this break from their pain, they can feel trapped and the need to find another way to escape their pain can increase. This study explains just how high of a risk factor insomnia is, explaining that frequent lack of sleep is, “linked to a five-fold increased risk of suicide in both the general and chronic pain populations”

How this should influence medical treatment?

Medical professionals must take this risk of suicide in chronic pain patients more seriously. In order to reduce the high numbers of completed suicides in chronic pain patients, the system must incorporate this risk into treatment.

  • Education for medical professionals

Doctors must be given the appropriate education and training to be able to advise chronic pain patients of the very effective treatments which are available. Stigma must be reduced within the doctor’s office and more compassionate ways of dealing with pain patients emphasised so that nobody feels they cannot reach out for help for their pain or for their mental health for fear of being judged.

  • Regular suicide screening

Chronic pain patients should be given regular mental health assessments and suicide screening as well as monitoring their physical health. This will enable doctors to recognise when somebody is more at risk of suicide so that they can help before it’s too late! This study explains that the vast majority of the suicide risk factors we have discussed are, “amenable to change through targeted intervention, highlighting the importance of comprehensively assessing chronic pain patients at risk for suicide”.

Those who are identified as at high risk of suicidal ideation should not be prescribed opioids. If they are already on a course of opioids, they should be monitored even more closely to ensure that they are safe as explained here: “clinicians treating patients with pain who are receiving higher doses of opioids should be aware of the increased suicide risk and monitor suicidal thoughts and plans in these patients.”

It’s so important that this monitoring is done in a way that is respectful and doesn’t make the patient feel as though their chronic pain is being dismissed. If we are treated with compassion and we understand the motivation behind the actions of medical professionals, we are far more likely to reach out for help.

  • Treating the patient as a whole

Pain clinics and other chronic pain treatments should address both the patient’s mind and body, teaching the patient healthy coping skills and dealing with comorbid mental health conditions as well as the physical aspect of care. It’s vital that the way our minds and bodies can influence one another is taken into consideration in treatments. This study states that “the addition of suicide prevention materials to pain-coping skills training programs, may benefit large numbers of individuals who are at elevated suicide risk as a consequence of chronic pain.”

Self-help

If you’re feeling suicidal, there are ways that you can help yourself:

  • Talking to someone you trust

Reach out to a family member or friend, anybody who you trust and feel comfortable around. You don’t even have to talk about feeling suicidal if you don’t feel comfortable with it; you can talk about other feelings and what you are going through. Or you can even talk about something completely different! Sometimes the act of just chatting to someone you feel close to can be comforting and helps you to feel less alone.

  • Monitoring your moods

Keeping an eye on your moods if you think you’re at risk can allow you to see early signs that your mood may be dipping. This can enable you to reach out for help before things progress.

  • Finding others who have chronic pain

Whether it’s online or through a local support group, finding other people with chronic pain can make you feel less alone. Often those who really understand what you are going through can offer the best advice and guidance regarding how to deal with your feelings and your pain.

  • Seeking treatment for your chronic pain

Finding treatment for your chronic pain can reduce your symptoms and equip you with the tools you need to cope, dealing with the risk factors of suicidal feelings head-on. Often treatments will involve psychological treatments, physical therapy and medication for example. You can find treatment by advocating for yourself with your doctor, seeking treatment privately or finding treatment online through a chronic pain relief app.

  • Self-educating

Finding out more about the science behind chronic pain can give you a sense of empowerment. It can help you with seeking treatment and allow you to find ways to manage your pain more effectively day to day. There are lots of blogs, articles and studies which you can find online.

  • Asking for help

If you are feeling suicidal, please reach out for help. I know that can feel like the last thing you want to do, but please know that these feelings are temporary and that things can get better.

Living with bipolar disorder, feeling suicidal has been part of my life for as long as I can remember. It’s always a risk for me, something that I must monitor and actively manage to ensure that I am safe. I’ve been to rock bottom and had many near misses, but I’m still standing and what is so important, is that I am so glad I am still here! Those feelings pass even though they feel like they will be forever at the time, and there is happiness ahead!

So, if you’re out there and you’re struggling, please know that you are not alone and that you can get through this. Call a friend or family member, go to your doctor, go the hospital, call the emergency services, or call a hotline (here is a list of international suicide prevention hotlines). The world needs you, and you can find happiness again.

References

  • Pain Medicine, Volume 12, Issue suppl_2, Martin D. Cheatle, PhD, (2011), “Depression, Chronic Pain, and Suicide by Overdose: On the Edge”
  • Pain, Volume 126, Issues 1–3, Pages 272-279, Robert R.Edwards, Michael T.Smith, Ian Kudel, Jennifer Haythornthwaite, (2006), “Pain-related catastrophizing as a risk factor for suicidal ideation in chronic pain”
  • Pain Practice, Volume 12, Issue 8, Pages 602-609, Kathryn E. Kanzler PsyD Craig J. Bryan PsyD, ABPP Donald D. McGeary PhD, ABPP Chad E. Morrow PsyD, ABPP, (2012), “Suicidal Ideation and Perceived Burdensomeness in Patients with Chronic Pain”
  • Neuropsychiatric Disease and Treatment, Irene Jimenez-Rodríguez, Juan Miguel Garcia-Leiva, Beatriz M Jimenez-Rodriguez, et al, (2014), “Suicidal ideation and the risk of suicide in patients with fibromyalgia: a comparison with non-pain controls and patients suffering from low-back pain”
  • Pain, Mark A. Ilgen, PhD, Amy S. B. Bohnert, PhD, Dara Ganoczy, MPH, et al, (2016), “Opioid dose and risk of suicide”
  • Annals of Internal Medicine, Emiko Petrosky, MD, MPH; Rafael Harpaz, MD, MPH; Katherine A. Fowler, PhD, et al., (2018), “Chronic Pain Among Suicide Decedents, 2003 to 2014: Findings From the National Violent Death Reporting System “
  • Progress in Neuro-psychopharmacology and Biological Psychiatry Racine M, (2018), “Chronic pain and suicide risk: A comprehensive review.”
  • Suicide and Life-Threatening Behavior: Vol. 31, No. 1, pp. 32-40, Ariel Stravynski, Richard Boyer, (2001), “Loneliness in Relation to Suicide Ideation and Parasuicide: A Population-Wide Study”
  • Indian Journal of Psychiatry, M. K. Srivastava, R N Sahoo, L H Ghotekar, Srihari Dutta, et al, (2004), “Risk Factors Associated with Attempted Suicide : A Case Control Study”
  • Open Access Text, Joseph V Pergolizzi Jr, Steven Passik, Jo Ann LeQuang, et al, (2018), “The risk of suicide in chronic pain patients”
  • Pain, Volume 89, Issues 2–3, Pages 199-206, Betty J Fisher, Jennifer AHaythornthwaite, Leslie J Heinberg, MichaelClark, JefferyReed, (2001), “Suicidal intent in patients with chronic pain”
  • Internal Bipolar Foundation, (2019), “List Of International Suicide Hotlines”

Please note: This article is made available for educational purposes only, not to provide personal medical advice.

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