Depression and Suicidal Behavior in Patients with Chronic Pain

There’s a robust body of literature on the comorbidity of depression, anxiety and chronic pain. Approximately 50 percent of patients who suffer from chronic nonmalignant pain suffer from some degree of depression. With respect to pain patients and suicidal ideation the prevalence is anywhere between 18 to 50 percent.  If you look at individuals who suffer from disease of addiction or substance use disorders, it’s equally as high a prevalence.  If you take someone who has the dual disease of pain and substance use disorder, it’s basically a powder keg.  Part of the issue of how I got interested in the field of pain, depression and suicide is that there was a lot of discussion around the unintentional overdose of opioid analgesics. But these are very brittle people who have significant psychiatric, psychological problems, many losses in their life including jobs, family roles and who’s to say that it’s unintentional?  I think there’s a subgroup of people that are what I call the silent minority or majority that suffer from depression and have thoughts of ending their life.

Primary care physicians really are the ones on battleground taking care of these patients. They prescribe probably over 50 percent of the opiates. They also have the least amount of resources.They obviously are not a pain psychologist or psychiatrist, but they need to be cognizant of the risk factors can exacerbate pain, depression and suicidal thought. One area that they can focus on is sleep disturbance. Sleep disorders are very common in pain patients and in people with substance use disorders. We know from the literature is that people who have sleep disorders suffer more pain due to the increase in cytokines, which is a pro-inflammatory process.  We also know from human experimental studies that when people are sleep deprived, particularly REM sleep deprived, that it actually decreases their pain tolerance. So patients get into the cycle of poor sleep, pain, pain causing sleep problems and it can cause this whole cycle that leads to more depression, more anxiety, more despair. I think that we don’t aggressively treat sleep disorders in pain patients. There are some very effective treatments, both pharmacologically and non-pharmacologically, such as cognitive behavioral therapy, insomnia, sleep hygiene, along with the right use of certain medications that can restore sleep, which would actually decrease the risk of suicide and also probably improve pain. Another factor that is involved in the relationship between pain and suicide is catastrophizing; the ‘oh my God, oh my God, oh my God, my pain is going to get worse.’ Again, there are effective interventions for this.

So I think that if the primary care physician sees certain pattern changes, such as the patient presenting with more anxiety, more stress, they’ve had recent losses like a divorce, lost their job, lost roles and they suffer from depression, be aware that puts them in an elevated risk for at least suicidal ideation if not behavior. Be aware of these different risk factors that can congeal into a very dangerous situation.