Pain. 2001 Jan;89(2-3):199-206.  

Suicidal intent in patients with chronic pain.

Fisher BJ, Haythornthwaite JA, Heinberg LJ, Clark M, Reed J.

Department of Psychiatry, Cook County Hospital, Chicago, IL, USA.

    Suicidal ideation among individuals suffering from chronically painful conditions has not been widely studied, although rates of completed suicide are believed to be elevated in this population relative to the general population. The psychiatric literature on suicide documents the importance of controlling for the severity of depression when studying factors associated with suicidal ideation, attempts, or completion. The present study examined the relationships between suicidal ideation and the experience of pain, pain-related disability, and pain coping efforts among a sample of individuals experiencing chronically painful conditions. Of 200 patients evaluated on an inpatient rehabilitation unit in a psychiatric service, 13 individuals (6.5%) reported suicidal intent on a commonly used self-report measure of symptoms of depression, the Beck Depression Inventory. This group was compared to a matched (age, sex, pain duration) group of similarly depressed individuals (N=13) and a matched group of non-depressed individuals (N=13) on measures of pain, disability, pain beliefs, and pain coping strategies. A history of a suicide attempt was associated with suicidal intent. Family history of substance abuse was significantly more prevalent among the depressed groups, regardless of suicidal thinking. The depressed/suicidal group and depressed/non-suicidal groups reported higher levels of pain, higher levels of pain-related disability, lower use of active coping, and higher use of passive coping compared to the non-depressed group. The depressed groups did not differ from one another on any of the measures of pain experience. Depression, not suicidal status, consistently predicted level of functioning. The prevalence of suicidal intent was comparable to rates observed in other studies and relatively low. When individuals with chronic pain report suicidal intent, it is imperative that measures preventing self-harm be implemented immediately and the patient's depression be treated aggressively.


Semin Clin Neuropsychiatry. 1999 Jul;4(3):221-7. 

The association of chronic pain and suicide.

Fishbain DA.

University of Miami School of Medicine, South Shore Hospital, Miami Beach, FL 33139, USA.

    Chronic pain patients (CPPs) are at greater risk for depression than the general population. As such, one would expect suicidal ideation, suicide attempts, and suicide completions to be commonly found within chronic pain (CP) populations. To explore these issues, 18 studies relating to the association of CP and suicide were subjected to a structured review. These studies indicated that suicide ideation, suicide attempts, and suicide completions are commonly found in CPP populations. In addition, a number of controlled studies and suicide completion rate studies indicated that CP may be a suicide risk factor. Finally, a review of known suicide risk factors from other populations indicated that CP populations commonly exhibit other suicide risk factors. Psychiatric examiners should consider CP to be a potential suicide risk factor. In addition, in all CPPs exhibiting suicidal behavior, a careful search for associated comorbid suicide risk factors should be initiated.


Clin J Pain. 1992 Jun;8(2):164-9.  

Early detection measures and triage procedures for suicide ideation in chronic pain patients.

Livengood JM, Parris WC.

Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee 37232.

    There is a dearth of writings about early detection of potential suicide patients in chronic pain centers. Early detection measures used at the Vanderbilt Pain Control Center include a Symptom Checklist-90, with questions about depressive symptomatology and "Thoughts of Ending Your Life"; medical and psychological interviews; monitoring of changes in emotional disturbance; and, if warranted, administration of the Scale of Suicidal Ideation. Three case studies are presented that indicate that the results of an assessment measure should be tempered with clinical judgment. Suicidal behavior, including suicidal ideation, is a medical emergency; therefore, there is great need for early detection and triage measures.


 Neurology. 1995 Dec;45(12 Suppl 9):S11-6; discussion S35-6.  

Central pain: diagnosis and treatment strategies.

Gonzales GR.

Department of Neurology, Mayo Clinic Scottsdale, AZ 85259, USA.

    The pathophysiology of central pain (CP) remains poorly understood. The paucity of objective findings on clinical examination of some of these patients can add to the difficulty in establishing a concrete diagnosis of CP. A pathophysiologic conceptual framework has been established to provide guidance. The goal of treatment should be pain reduction rather than complete pain relief. Surgical procedures have been used for specific causes of CP, but no one surgical technique helps relieve pain over the long term in all CP patients. Likewise, no one pharmacologic agent is successful in all CP patients, and pain relief is often incomplete. Pharmacologic treatment may take the form of stepwise addition of various agents, the cornerstone of which are antidepressants, followed by anticonvulsants, opioids, and other drugs. If all standard pharmacologic treatments fail, treatment of psychological problems induced by chronic pain is necessary since depression and the risk of suicide are significant in patients with poorly controlled CP.


J Psychosoc Nurs Ment Health Serv. 1992 Feb;30(2):29-34.  Related Articles, Links  

Suicide among elderly white men: development of a profile.

Mellick E, Buckwalter KC, Stolley JM.

Viterbo College, LaCrosse, Wisconsin.

    1. Older white men have the highest suicide rate in the nation; a linear increase of suicide occurs with each passing year of chronological age. 2. Elderly who attempt suicide are more likely to communicate their intentions less frequently and to use violent and lethal means. 3. Chronic sleep problems, pain, degenerative illness, or clinical depression may be experienced by older white men at suicidal risk; somatic complaints including imaginary symptoms can mask depression. 4. Educational programs, outreach mental health programs, and enhanced consultation/coordination improve case findings and early intervention. Holistic nursing care, including pain alleviation, depression assessment, and simple comfort measures, are imperative in suicide prevention in the elderly.


Clin J Pain. 1989 Sep;5(3):275-7.  Related Articles, Links  

Comment in:
Clin J Pain. 1990 Jun;6(2):160-6.

Homicide-suicide and chronic pain.

Fishbain DA, Goldberg M, Rosomoff RS, Rosomoff HL.

University of Miami, School of Medicine, Miami Beach, Florida.

    Homicide-Suicide (H-S) is a form of dual death where the murder is closely followed by the suicide of the perpetrator. H-S is extremely rare and has not previously been described within the chronic pain patient population. Such a case is presented. Psychiatric examination data from the victims of H-S revealed a number of complex, psychiatric, social, vocational, and litigation problems. Demographically the case displays some characteristics associated with suicide pacts.


Am J Public Health. 1995 Oct;85(10):1452-3.  Related Articles, Links  

Back pain and risk of suicide among Finnish farmers.

Penttinen J.


Clin J Pain. 1991 Mar;7(1):29-36.

Completed suicide in chronic pain.

Fishbain DA, Goldberg M, Rosomoff RS, Rosomoff H.

    Department of Psychiatry, University of Miami School of Medicine, Florida.

Although convergent lines of evidence indicate that one can expect a high rate of suicide completion for chronic pain patients, this problem has not previously been investigated. Follow-up data from our pain center revealed three chronic pain patients (two men and one woman) who completed suicide. These three cases are presented. The sequential nature of the data enabled us to calculate suicide rates for our chronic pain population and subsamples of this population: 16.5 women per year; 29.3 men per year; 57.1 white men and 34.9 white women in the age range of 35-64 years per year; and 78.6 white worker compensation men in the age range of 35-64 years per year. Calculation of the 95% confidence interval and comparison of these suicide rates to the general population of the United States using the Z statistic indicated that all chronic pain patient suicide rates were significantly greater than that of the general population. White men, white women, and white worker compensation men with chronic pain in the age range of 35-64 years are twice, three, and three times as likely, respectively, as their counterparts in the general population to die by suicide. Although no firm conclusions can be drawn because of the small suicide sample, these case reports indicate a need for further studies of chronic pain patient suicide rates at other pain centers.


 Psychother Psychosom. 1994;61(1-2):65-73.  

Attempted suicide, depression and physical diseases: a 1-year follow-up study.

Stenager EN, Stenager E, Jensen K.

Department of Psychiatry, Odense University, Denmark.

    In the period January 1, 1990 to March 31, 1991 a sample of suicide attempters admitted to the Department of Psychiatry, Odense University Hospital, underwent a structured interview. In the study 52% of the patients interviewed were found to suffer from a somatic disease, and 21% were daily on analgesics for pain. Patients that suffered from a somatic disease differed from other suicide attempters in depression score, age, pain and the presence of psychosis. Fewer of the somatically ill suicide attempters had a psychosis. Patients complaining of pain were more often depressed and abused medicine. Statistically, the risk of repetition of parasuicide for patients with a somatic disease but without depression was significantly less. The 7 patients committing suicide were older and a tendency was found towards painful somatic diseases and depression as risk factors for suicide.


 Psychother Psychosom. 1995;63(1):54-5.  Links 

Comment on:
Psychother Psychosom.

Chronic pain and suicide.

Fishbain DA.


 Clin J Pain. 2004 Mar-Apr;20(2):111-8.  Related Articles, Links  
Suicidal ideation in outpatients with chronic musculoskeletal pain: an exploratory study of the role of sleep onset insomnia and pain intensity.


Smith MT, Perlis ML, Haythornthwaite JA.


Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287, USA.


OBJECTIVES: Sleep disturbance, depression, and heightened risk of suicide are among the most clinically significant sequelae of chronic pain. While sleep disturbance is associated with suicidality in patients with major depression and is a significant independent predictor of completed suicide in psychiatric patients, it is not known whether sleep disturbance is associated with suicidal behavior in chronic pain. This exploratory study evaluates the importance of insomnia in discriminating suicidal ideation in chronic pain relative to depression severity and other pain-related factors. METHODS: Fifty-one outpatients with non-cancer chronic pain were recruited. Subjects completed a pain and sleep survey, the Pittsburgh Sleep Quality Index, the Beck Depression Inventory, and the Multidimensional Pain Inventory. Subjects were classified as "suicidal ideators" or "non-ideators" based on their responses to BDI-Item 9 (Suicide). Bivariate analyses and multivariate discriminant function analyses were conducted. RESULTS: Twenty-four percent reported suicidal ideation (without intent). Suicidal ideators endorsed higher levels of: sleep onset insomnia, pain intensity, medication usage, pain-related interference, affective distress, and depressive symptoms (P < 0.03). These 6 variables were entered into stepwise discriminant function analyses. Two variables predicted group membership: Sleep Onset Insomnia Severity and Pain Intensity, respectively. The discriminant function correctly classified 84.3% of the cases (P < 0.0001). DISCUSSION: Chronic pain patients who self-reported severe and frequent initial insomnia with concomitant daytime dysfunction and high pain intensity were more likely to report passive suicidal ideation, independent from the effects of depression severity. Future research aimed at determining whether sleep disturbance is a modifiable risk factor for suicidal ideation in chronic pain is warranted.


Aging Clin Exp Res. 2003 Apr;15(2):99-110.  Related Articles, Links  


Suicide and euthanasia in late life.


De Leo D, Spathonis K.


Australian Institute for Suicide Research and Prevention, Griffith University, Brisbane, Queensland, Australia.


Epidemiological studies of suicide in the elderly indicate that, in the last few decades, there has been a relevant increase in suicide rates in old age in a number of Asian and Latin nations, with an almost parallel decrease in Anglo-Saxon counties. Mental disorders, particularly depression, physical illness, personality traits such as hostility, hopelessness, the inability to verbally express psychological pain and dependency on others, recent life events and losses are all factors that may contribute to suicide in later life. Compared with suicide in other age groups, mors voluntaris in late life is associated with the use of highly lethal methods, less ambivalence and impulsivity, and more determination and intent to die. Accordingly, elderly suicidal individuals are more likely than younger subjects to complete rather than attempt suicide. Some evidence suggests also that the characteristics of elderly individuals who attempt suicide may not overlap with those who complete suicide. Death thoughts and suicidal ideations are relatively rare among mentally healthy elderly adults, and are less predominant in this age bracket. However, whether elderly suicidal behaviour exists along a continuum, progressing in severity from death thoughts and suicidal ideation to suicide attempts and completed suicide, remains unclear. Assisted suicide and euthanasia in the elderly have been associated with the desire to escape chronic physical pain and suffering caused by terminal illness, and to relieve mental anguish and feelings of hopelessness, depression and extreme "tiredness of life." The role of the family and those treating chronically ill members is crucial in the final stages of life, particularly when autonomy and the ability of the elderly individual to make end-of-life decisions are compromised. The main aspects associated with these controversial phenomena, particularly from a transcultural perspective, are reviewed in this article.


 J Am Med Womens Assoc. 2003 Winter;58(1):44-8.  Related Articles, Links  

Antecedents of euthanasia and suicide among older women.

Roscoe LA, Malphurs JE, Dragovic LJ, Cohen D.

Department of Internal Medicine, College of Medicine, University of South Florida, MDC 19, 12901 Bruce B Downs Blvd, Tampa, FL 33612-4799, USA.

    OBJECTIVES: To identify the characteristics of older women who sought Jack Kevorkian's assistance in dying and to compare them with those of an age-matched sample who committed suicide. METHOD: This retrospective case-control study compared all 18 women age 55 and older who died with the assistance of Jack Kevorkian and whose deaths were investigated in Oakland County, Michigan from 1995 to 1997 with all 15 women age 55 and older who committed suicide in the same county during the same time period. We coded 203 variables in 7 domains from medical examiner files, including autopsy findings. RESULTS: Significantly more of Kevorkian's cases had amyotrophic lateral sclerosis or multiple sclerosis (p = .018), a recent decline in health (p = .031), or inadequately controlled pain (p = .041). Women who committed suicide had more prevalent chronic illnesses and were more likely to have been diagnosed with clinically significant depression or other psychiatric disorders (p = .023). Both groups were significantly less likely to be married (p < .001) and more likely to be divorced (p < .001) than US Census data would predict. CONCLUSIONS: The different vulnerabilities of older women who want to die and either commit suicide or seek assistance deserve continued careful research. Poorly controlled pain was a factor in seeking assistance in dying, and depression and psychiatric disorders characterized older women who committed suicide in our study. Not having a spouse may increase isolation and reinforce the hopelessness of women who are living with catastrophic illness.


BMJ. 2001 Sep 22;323(7314):662-5.  Related Articles, Links  

Comment in:
BMJ. 2002 Feb 2;324(7332):300.
BMJ. 2002 Feb 2;324(7332):300.
Widespread body pain and mortality: prospective population based study.

Macfarlane GJ, McBeth J, Silman AJ.

Unit of Chronic Disease Epidemiology, Medical School, University of Manchester, Manchester M13 9PT.

    OBJECTIVE: To determine whether there is excess mortality in groups of people who report widespread body pain, and if so to establish the nature and extent of any excess. DESIGN: Prospective follow up study over eight years. Mortality rate ratios were adjusted for age group, sex, and study location. SETTING: North west England. PARTICIPANTS: 6569 people who took part in two pain surveys during 1991-2. MAIN OUTCOME MEASURES: Pain status at baseline and subsequent mortality. RESULTS: 1005 (15%) participants had widespread pain, 3176 (48%) had regional pain, and 2388 (36%) had no pain. During follow up mortality was higher in people with regional pain (mortality rate ratio 1.21, 95% confidence interval 1.01 to 1.44) and widespread pain (1.31, 1.05 to 1.65) than in those who reported no pain. The excess mortality among people with regional and widespread pain was almost entirely related to deaths from cancer (1.55 (1.09 to 2.19) for regional pain and 2.07 (1.37 to 3.13) for widespread pain). The excess cancer mortality remained after exclusion of people in whom cancer had been diagnosed before the original survey and after adjustment for potential confounding factors. There were also more deaths from causes other than disease (for example, accidents, suicide, violence) among people with widespread pain (5.21, 0.94 to 28.78). CONCLUSION: There is an intriguing association between the report of widespread pain and subsequent death from cancer in the medium and long term. This may have implications for the long term follow up of patients with "unexplained" widespread pain symptoms, such as those with fibromyalgia.


 Pain. 1998 May;76(1-2):137-44.  

Suicidality in chronic abdominal pain: an analysis of the Hispanic Health and Nutrition Examination Survey (HHANES).

Magni G, Rigatti-Luchini S, Fracca F, Merskey H.

F. Hoffmann-La Roche, Ltd., Basel, Switzerland.

    The objective of this study was to explore the relationship between suicidal ideation, suicidal attempts, depression and chronic abdominal pain in data gathered during a systematic epidemiologic survey, the Hispanic Health and Nutrition Examination Survey of the United States National Centre for Health Statistics. The material comprises data collected between 1982 and 1984 in samples of Hispanic groups in the United States. A sub-sample which initially comprised 5498 subjects had provided answers to questions concerning the thoughts about death, wishes to die, thoughts of committing suicide and suicide attempts, as well as information about complaints of chronic abdominal pain and responses to the Centre for Epidemiologic Studies Depression Scale (CES-D). Complete answers were available from 4964 subjects. The data were analyzed by tabulation, and logistic regression analyses. The lifetime prevalence of suicidality was much increased in subjects with pain compared with those without chronic abdominal pain. Rates for thoughts about death, wishing to die, suicidal ideation and suicide attempts were 2- to 3-times more frequent in those with chronic abdominal pain compared with those without. Logistic regression analyses and the calculation of odds ratios confirmed that the most powerful predictive factors for suicidality were first, the presence of significant depressive ideation, and second, the presence of chronic abdominal pain. There is a strong relationship between chronic abdominal pain and suicidality in the Hispanic population in the United States. This was particularly evident in the Puerto Rican population of the United States where both rates were much increased compared with other Hispanic citizens. The present data are new, but no conclusion can be drawn concerning causality because they are cross-sectional. They indicate the importance of the link between chronic abdominal pain and depression in this population.