The Role of Pain, Functioning, and Mental Health in Suicidality Among Veterans Affairs Primary Care Patients

摘要

Objectives. We examined suicidality, pain, functioning, and psychiatric disorders among veterans in primary care by using both self-report and clinical measures of pain and mental health to determine correlates that might be clinically useful in primary care settings. Methods. Data were from 884 Veterans Affairs patients enrolled in a regional 4-site cross-sectional study. Patients were administered measures that assessed functioning (including pain) and psychiatric disorders. Data were merged with medical records for clinical pain indicators. Results. Overall, 9.1% (74 of 816) of patients indicated suicidal ideation, with those who were middle-aged, unemployed because of disability, had less than college education, and served in a warzone most likely to consider suicidality. Suicidal patients had worse functioning (measured by the Short Form-36) than did nonsuicidal patients in every domain, including bodily pain, and were more likely to meet criteria for a psychiatric diagnosis. However, when pain and mental health were jointly considered, only mental health (both psychiatric diagnosis and mental health functioning) was related to suicidality. Conclusions. Although providers should be alert to the possibility of suicidality in patients with pain, they should be vigilant when patients have a psychiatric disorder or poor mental health. Military veterans are more likely to commit suicide than nonveterans. Based on a large, nationally representative sample (n?=?320?890), a recent publication reported that military veterans were twice as likely to commit suicide as nonveterans. 1 Chronic pain and depression—2 conditions not uncommon in Veterans Affairs (VA) medical settings—are leading contributing factors in deaths by suicide. A systematic literature review of pain and suicide, suicide attempts, and suicidal ideation revealed that patients with chronic pain had a 2-fold risk of death by suicide, a 14% prevalence of suicide attempts (compared with 5% without chronic pain), and a 20% prevalence of suicidal ideation. 2 The relationship between depression, as well as other psychiatric disorders, and suicidality is well established. 3–5 Older age and male gender are also highly related to suicide, 6 as are lower socioeconomic status 7,8 and unemployment 8 —all being predominant characteristics of the VA patient population. In a study that analyzed data from the National Comorbidity Survey Replication sample, suicidal thoughts and behaviors were associated with self-reported medical conditions presumed to accompany pain (e.g., arthritis or rheumatism, chronic back or neck problems). 9 After controlling for mood and anxiety disorders, this association with pain-related conditions persisted for lifetime measures of suicidality (suicidal ideation, plan, or attempt); however, for current measures of suicidality, it only persisted for those who reported a suicide attempt. In a large study of VA service users, self-reported severe pain was predictive of subsequent suicide, even after controlling for physician-diagnosed psychiatric comorbidity. 10 Of note, this study used a single question from the Short Form-36 (SF-36) to measure pain severity. 11 Although mental health settings are most often associated with detection and management of suicidal patients, primary care can potentially play an important part. Luoma et al. 12 found that 45% of those who committed suicide had contact with a primary care provider (PCP) in the month before suicide, thus highlighting the importance of PCPs in identifying and intervening with the 2% to 3% of primary care patients who display suicidal ideation. 6 The fact that pain is also very common in primary care patients and is one of the main reasons for seeking medical care 13,14 is further argument for including primary care clinics in planning for effective suicide prevention programs. Interestingly, in the studies reviewed there was little attention given to functioning associated with pain. It might be that the functional limitations imposed by pain—as much as pain itself—might cause individuals to turn their thoughts to self-destruction. Furthermore, there was little attention to the relationship between pain and psychiatric distress (e.g., pain might cause symptoms of depression, and depression might exacerbate the sense of pain). Thus, our overall objective was to examine suicidality, pain, functioning, and psychiatric disorders among veterans in primary care, determining meaningful correlates that might prove to be clinically useful, especially in primary care settings.