Predicting Suicidal Ideation in Veterans With Chronic Pain

A number of factors including chronic pain co-occurring with posttraumatic stress disorder and pain interference may predict suicidal ideation and violent impulses in US veterans with chronic pain.

A number of factors, including chronic pain co-occurring with posttraumatic stress disorder (PTSD) and pain interference, may predict suicidal ideation and violent impulses in US veterans with chronic pain, according to a study published in the Journal of Pain.

For this study, data on pain variables, traumatic brain injury (TBI), clinical diagnoses, drug abuse and suicidal ideation were collected through self-reports of 667 US veterans, National Guard and Reserve members, and active-duty personnel with chronic pain who had served in these organizations since September 11, 2001.

All participants had chronic back pain for ≥7 months before enrollment, with 94.5% reporting chronic pain for >12 months. Pain intensity and pain interference were assessed with the Brief Pain Inventory-Short Version.

Presence of PTSD and major depressive disorder (MDD) was evaluated using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition, and alcohol and drug abuse were assessed with the Alcohol Use Disorders Identification Test and Drug Abuse Screening Test, respectively. A score ≥3 on the 19-item Beck Scale for Suicidal Ideation (BSS) or a score >0 on the suicidal ideation item of the Beck Depression Inventory-II (BDI-II) indicated the presence of suicidal impulses.

Suicidal ideation (n=62 using both scales; n=25 with the BSS but not with the BDI; n=40 with the BDI-II but not with the BSS) was found to be associated with chronic pain plus PTSD, alcohol/drug abuse, pain interference and intensity, and MDD symptoms (P <.01 for all), and violent impulses, with the same factors, with the exception of drug abuse (P <.01 for all). In addition, younger participants were more likely report violent ideation than older participants (P <.05).

Logistic regression analyses indicated that white race and pain interference were predictors of suicidal ideation in veterans with chronic pain (P <.01 and P <.001, respectively). The addition of polytrauma variables led to the identification of other predictors of risk for suicide: chronic pain with PTSD (P <.001) and TBI plus PTSD (P <.01). The addition of other clinical variables led to pain interference and co-occurring chronic pain/TBI/PTSD (the “polytrauma clinical triad”) no longer being associated with suicide ideation.

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Both younger age and pain interference (P =.01 and P <.001, respectively) were found to be associated with violent impulses. Younger age (P =.02), pain interference (P <.001), and PTSD with TBI (P <.001) were also associated with violent impulses in this sample when adding polytrauma variables, and MDD (P <.01) and drug abuse (P =.02) were associated with higher violent impulses after the addition of other diagnostic variables.

The inability to draw causal links between the studied variables and suicide/violent ideation risks represents a study limitation.

“Our findings underscore the need for interdisciplinary and/or coordinated care for veterans presenting with chronic pain or some combination of chronic pain, TBI, and PTSD to ensure that important suicide and violence risk factors are not overlooked by a patient’s treatment team,” concluded the study authors.

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Blakey SM, Wagner HR, Naylor J, et al. Chronic pain, TBI, and PTSD in military veterans: A link to suicidal ideation and violent impulses? [published in March 8, 2018]. J Pain. doi: 10.1016/j.jpain.2018.02.012