The Mediating Effect of Sleep Disturbance on the Relationship Between Nonmalignant Chronic Pain and Suicide Death

Abstract

Importance Few studies have examined the relationship between nonmalignant chronic pain (NMCP) and suicide death, and even fewer have specifically explored what role sleep disturbance might play in the association between NMCP and suicide death. Objective To assess whether sleep disturbance mediates the relationship between NMCP and suicide death. Design This case‐control study included 2,674 individuals who died by suicide between 2000 and 2013 (cases) and 267,400 matched individuals (controls). Setting Eight Mental Health Research Network (MHRN)‐affiliated healthcare systems. Participants All cases and matched controls were health plan members for at least 10 months during the year prior to the index date. Main Outcomes and Measures Sociodemographic data and diagnosis codes for NMCP and sleep disorders were extracted from the MHRN's Virtual Data Warehouse. Suicide mortality was identified using International Statistical Classification of Diseases and Related Health Problems (ICD)‐10 codes from official government mortality records matched to health system records. Results After accounting for covariates, there was a significant relationship between NMCP and sleep disturbance; those who were diagnosed with NMCP were more likely to develop subsequent sleep disturbance. Similarly, sleep disturbance was significantly associated with suicide death. Finally, a significant indirect effect of NMCP on suicide death, through sleep disturbance, and a nonsignificant direct effect of NMCP on suicide death provide support for a fully mediated model. Conclusions and Relevance There is a need for clinicians to screen for both sleep disturbance and suicidal ideation in NMCP patients and for health systems to implement more widespread behavioral treatments that address comorbid sleep problems and NMCP.

Identifying and Managing Suicidality in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome

“…Although this is a troubling implication for suicide in ME/CFS, it also represents a salient opportunity for intervention; treating sleep dysfunction could be a practical way to reduce suicide risk and increase quality of life for people with ME/CFS. In a study of nonmalignant chronic pain-another common experience for those with ME/CFS-a significant indirect effect of chronic pain on suicide risk was found, mediated by disturbed sleep; with sleep removed from the model, the direct effect of chronic pain on suicide risk was nonsignificant [24]. Another highly relevant risk factor is functional limitation.…”

Using Administrative Data to Predict Suicide After Psychiatric Hospitalization in the Veterans Health Administration System

“…Psychopathological risk factors: We created 3 variables for each of 7 retrospective time periods (past 30, 90, 180, 365, 730, 1,095 days and the veterans' entire VHA history as of January 1, 2000) for each of the 582 diagnoses or diagnostic groupings of mental disorders in the ICD-9-CM and each of the 41 mental disorder diagnoses in the Clinical Classification Software (41): yes/no for any visit with this diagnosis during the time period; a continuous count of number of days with such visits; and a stabilized 0-4 quintile transformation of the latter count. We also created a series of composite variables for common types of comorbidity among these disorders, including comorbidities thought to predict suicide that involve a combination of mental and physical disorders [e.g., (42)(43)(44)]. ICD-9-CM codes and details about each disorder are presented in Supplementary Table 4.…”

The Mediating Role of Depressive Symptoms, Hopelessness, and Perceived Burden on the Association Between Pain Intensity and Late-Life Suicide in Rural China: A Case–Control Psychological Autopsy Study

“…As the duration of suffering pain increases, suicidal behaviors may be less related to pain symptoms (43). Also, prior studies had demonstrated that sleep disturbance was a mediator in the pain-suicidality link (19). Nevertheless, we did not include information on sleep quality.…”

“…Though the pain-suicidality link has been reported, the mechanism may be complicated. Limited studies investigated the mediation effect of psychological factors, including depression, anxiety, and sleep problem on pain and suicidality link with inconsistent results (17)(18)(19). Moreover, most studies on the pain-suicidality association focused on suicide ideation and suicide attempts.…”