Remission From Suicidal Ideation Among Those in Chronic Pain: What Factors Are Associated With Resilience?

Most research on suicidality has focused on identifying risk factors for suicidal ideation and behaviors,9x9Cavanagh, JTO, Carson, AJ, Sharpe, M, and Lawrie, SM. Psychological autopsy studies of suicide: A systematic review. Psychol Med. 2003;
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The current project attempts to address this research gap. As was indicated, we discuss both the bivariate and the logistic regression analyses because the former helps health professionals to identify the characteristics of their patients with chronic pain most at risk for continued suicidal ideation, and the latter provides information on the association between each characteristic and remission from suicidal thoughts independent of other characteristics. This study’s findings provide a very hopeful message. Despite a history of suicidal ideation and current chronic and disabling pain, 3 in 5 respondents were free of serious suicidal thoughts in the previous year. Those who were free of suicidal thoughts in the past year were older (49.9 years vs 44.8 years) and were more likely to be white, women, better educated, and with a confidant and more likely to use spirituality or religion to cope in comparison with those who had seriously considered suicide in the past year.

This study found that those in chronic pain who were in remission from suicidal thoughts were approximately 5 years older, on average, than those who were still experiencing suicidal ideation. The general literature on remission from suicidal ideation has also found older age to be associated with suicide remission.29x29Lynch, TR, Johnson, CS, Mendelson, T, Robins, CJ, Ranga, K, Krishnan, R, and Blazer, DG. New onset and remission of suicidal ideation among a depressed adult sample. J Affect Disord. 1999;
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Our results indicate that women had a significantly higher chance of remitting from suicidal ideation compared with men. At first this is surprising, because suicidal ideation is more prevalent in women.8x8Canetto, SS and Sakinofsky, I. The gender paradox in suicide. Suicide Life Threat Behav. 1998;
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Adults with former suicidal ideation and current chronic pain who had completed high school, compared with those without a high school diploma, were more likely to be free of suicidal thoughts. Clear links have already been made between lower education and higher likelihood of both suicidal thoughts32x32Nock, MK, Borges, G, and Ono, Y. Suicide: Global Perspectives from the WHO World Mental Health Surveys. Cambridge University Press,
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In this study, adults in chronic pain with previous suicidal ideation who reported that they were white had a higher prevalence of remission from suicidal thoughts than their non-white peers. Unfortunately, the public- use CCHS-MH dataset did not provide any additional information on race and ethnicity, so we could not explore any further the particular cultural or ethnic differences in remission. Possible reasons for this discrepancy to study in future research include potential racial disparities in access to mental health services, as well as treatment for chronic pain. Racialized Canadians earn approximately 20% less than their nonracialized counterparts3x3Block, S and Galabuzi, G. Canada’s colour coded labour market: The gap for racialized workers. The Wellesley Institute,
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Because baseline social support has been found to be a major predictor of remission from suicidal thoughts50x50Teismann, T, Forkmann, T, Glaesmer, H, Egeri, L, and Margraf, J. Remission of suicidal thoughts: Findings from a longitudinal epidemiological study. J Affect Disord. 2016;
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This study found that those who turned to religion or spirituality to cope with every day difficulties were more likely to recover from suicidal ideation. Forgiveness in the context of religion has been found to correlate positively with better mental health and lower pain intensity, whereas negative religious coping, such as feelings of abandonment by God, is positively correlated with higher pain intensity.41x41Rippentrop, AE, Altmaierb, EM, Chena, JJ, Founda, EM, and Keffalaa, VJ. The relationship between religion/spirituality and physical health, mental health, and pain in a chronic pain population. Pain. 2005;
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Various factors in this study were found to be barriers to remission from suicidal thoughts among those living with disabling pain. Living in poverty and struggling to meet basic living expenses were among these variables. Other research has shown that lower income4x4Borges, G, Angst, J, Nock, MK, Ruscio, AM, Walters, EE, and Kessler, RC. A risk index for 12-month suicide attempts in the national comorbidity survey replication (NCS-R). Psychol Med. 2006;
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is associated with an increased risk for both suicidal ideation and chronic pain.26x26Johannes, CB, Le, TK, Zhou, X, Johnston, JA, and Dworkin, RH. The prevalence of chronic pain in United States adults: Results of an internet-based survey. J Pain Symptom Manage. 2010;
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For example, one study of middle-aged women with fibromyalgia and/or osteoarthritis found that, compared with those without financial stress, individuals with daily financial worry experienced significantly higher levels of pain.40x40Rios, R and Zautra, AJ. Socioeconomic disparities in pain: The role of economic hardship and daily financial worry. Health Psychol. 2011;
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This study’s findings that individuals with chronic pain with a history of depression and anxiety disorders were less likely to remit from suicidal ideation, is consistent with literature on mood disorders and suicidality in the general population. Approximately 3 in 5 individuals who die by suicide have an affective disorder.9x9Cavanagh, JTO, Carson, AJ, Sharpe, M, and Lawrie, SM. Psychological autopsy studies of suicide: A systematic review. Psychol Med. 2003;
33: 395–405https://doi.org/10.1017/S0033291702006943
Crossref | PubMed | Scopus (985)
| Google ScholarSee all References

We were very surprised that three factors known to be associated with the onset of suicidal thoughts played no role in remission in either the bivariate or logistic regression analyses, namely, sleep disturbances, adverse childhood experiences, and substance abuse problems. Insomnia has been strongly associated with suicidal ideation in the general population and among those with chronic pain.49x49Tang, NK and Crane, C. Suicidality in chronic pain: A review of the prevalence, risk factors and psychological links. Psychol Med. 2006;
36: 575–586
Crossref | PubMed | Scopus (287)
| Google ScholarSee all References

When considering the findings of this study, it is important to consider the limitations of the data. Although the CCHS-MH did investigate the extent to which the respondent perceived that their chronic pain prevented their activities, it did not collect information on how long the pain had lasted. The literature is mixed regarding the impact of duration and intensity of chronic pain on suicidal behaviors; however, it is clear that death by suicide is more likely when chronic pain is severe.37x37Racine, M. Chronic pain and suicide risk: A comprehensive review. Prog Neuropsychopharmacol Biol Psychiatr. 2018;
87: 269–280https://doi.org/10.1016/j.pnpbp.2017.08.020
Crossref | PubMed | Scopus (15)
| Google ScholarSee all References

Despite these limitations, this study provides, to our knowledge, the first nationally representative population-based study of the topic indicating that more than 3 in every 5 adults with former suicidal ideation experiencing chronic and disabling pain have been free of suicidal thoughts in the preceding year. The study also provided information to improve targeting for those most vulnerable to ongoing suicidal thoughts, particularly racialized and younger adults, men, those without a high school diploma, those who are socially isolated, living in poverty, and those with a history of anxiety and/or depressive disorders.

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