Major Finding: Perceived burdensomeness was independently associated with suicidal ideation among patients with chronic pain, and a model including this measure correctly classified 95% of patients as to the presence or absence of suicidal ideation.
Data Source: A retrospective study of 109 patients in a military population with chronic pain referred to a psychology clinic.
Disclosures: Dr. Kanzler reported that she had no conflicts of interest related to the study.
SEATTLE – Asking patients with chronic pain a single question – “Do you believe it would be better for everyone involved if you were to die?” – can determine whether he or she is having suicidal thoughts or wishes, findings from a retrospective study suggest.
Among 109 patients with chronic pain, patients' perceptions that they were a burden to others as assessed with this question was the sole independent predictor of suicidal ideation even after depression and hopelessness were taken into account.
A model including perceived burdensomeness, in addition to conventional risk factors, correctly classified 95% of the patients regarding the presence or absence of suicidal ideation.
“It's important to consider perceived burdensomeness in the patients that you see,” advised lead investigator Kathryn E. Kanzler, Psy.D., who is a captain in the U.S. Air Force and a psychologist at Lackland Air Force Base in San Antonio. “Just one question – that's all it takes to get kind of a quick snapshot of what's going on.”
Patients with chronic conditions may be uniquely attuned to the impact of their health on their caregivers, Dr. Kanzler told attendees of the annual meeting of the Society of Behavioral Medicine. “Research has found that self-perceived burden … can have a direct impact on significant medical decision making,” she said, such as choosing to reduce or entirely skip dialysis.
In the study, she and her colleagues retrospectively reviewed the medical records of 109 outpatients with chronic pain who were referred to a psychology clinic for evaluation and possible behavioral and psychosocial interventions. All were active or retired military personnel, or their dependents or family members.
The patients were age 42 years on average. The majority were married (72%), female (65%), and white (66%).
The leading primary cause of pain was headache/migraine (seen in 28% of patients), followed by chronic low back pain (16%), fibromyalgia (13%), temporomandibular or myofascial pain (9%), arthritis (3%), and complex regional pain syndrome (1%). The remaining patients (30%) had pain due to other conditions, such as cancer or orthopedic injuries.
The investigators used responses on the Beck Depression Inventory–Second Edition (BDI-II) to assess patients' hopelessness, suicidal ideation, and depression.
Perceived burdensomeness was assessed from responses to a single statement, “It would be better for everyone involved if I were to die,” with possible response options ranging from 1 (never or none of the time) to 5 (always or a great many times).
Overall, 7% of patients were found to have suicidal ideation, Dr. Kanzler reported. A logistic regression model including age, sex, race, marital status, depression, and hopelessness improved the ability to predict suicidal ideation above a null model.
Adding patients' perceived burdensomeness to this model further improved the ability to predict suicidal ideation and also improved model fit.
When controlling for depression and hopelessness, perceived burdensomeness was the sole independent predictor of suicidal ideation.
There was no difference in the findings between patients who did and did not have an identified caregiver, a finding that corroborated those from other studies suggesting that perceived burdensomeness may apply to the people who are important in one's life generally.
Perceived burdensomeness performed better at correctly classifying patients without suicidal ideation (98%) than at correctly classifying those with suicidal ideation (63%).
“We hope this study adds to the understanding of the really complex relationship between chronic pain and suicide ideation,” Dr. Kanzler said. “Perceived burdensomeness as a risk factor might help explain high rates of suicide ideation beyond the types of things that definitely, immediately come to mind.”
Importantly, she noted, perceived burdensomeness is modifiable, in contrast to many of the other risk factors for suicidal ideation, such as age and sex. “Some kind of a cognitive intervention might be useful,” she proposed, such as intervening to change the meaning of the cognition of perceived burdensomeness or to challenge the cognition itself.
Encouraging increased communication with the key people in a patient's life may also be beneficial, according to Dr. Kanzler. “Sometimes, especially in our population, there is not necessarily an identified caregiver, but this perceived burdensomeness kind of affects the whole group that surrounds that person,” she explained. “So that type of intervention might also be useful, going beyond the individual patient.”