In the mid-1970s, Quality of Life (QOL) was identified as a key medical concept (Berlim and Fleck, 2003). Readily adopted in oncology, the concept spread through different fields of medicine and eventually to psychiatry. Many tools were developed to take QOL from a subjective concept to a measurable attribute. Some of these tools, such as the Quality of Life Interview and the Wisconsin Quality of Life Index, were designed specifically to measure QOL for individuals with severe and persistent mental illness.
Balazs et al. (2018) noted that QOL can be a significant mediator between peer and emotional problems and suicidal behavior in adolescents. Hoefer (2020), noting the sparsity of similar work with adults, found that life-altering events (divorce, grieving, isolation) significantly impacted the quality of life. Hoefer argued these became enabling conditions for attempting suicide.
Hadi et al. (2019) found that “The multidimensional negative impact of chronic pain leads to poorer QoL among patients with chronic pain compared to the general population and patients with other long-term conditions.” Chen et al. (2023) made a direct connection between chronic pain and suicidal behaviors. They found that scoring just one standard deviation above the mean for pain had a 51% higher risk of suicidal behavior. Many others have followed this path, and the link between chronic pain, quality of life, and suicidal behavior is now well established.
Themelis et al. (2023) emphasized, “Living with chronic pain has been identified as a significant risk factor for suicide.” In fact, after accounting for mental health disorders, 8.8% of deaths by suicide can be attributed to chronic pain. Using the most recently available suicide statistics, that is more than 4,000 people losing their lives to suicide because of chronic pain. We know that deaths by suicide are but a fraction of thoughts of suicide, so it is a significant factor in all suicidal behaviors. They discussed the concept of mental defeat as part of this link between chronic pain and suicidal behavior. Tracing the concept from work on trauma, they identified the link between mental defeat and chronic pain as being recognized by 2007, with “mental defeat defined as negative appraisals of self in relation to pain.” Catastrophic thinking about chronic pain can lead to this mental defeat.
Gibbs (2021) made a simple observation that “suicide happens when the outward pressures of life are greater than the inward ability to cope in that moment.” Chronic pain leads to catastrophic thinking, leads to mental pain, leads to suicidal behavior. The pain simply becomes too much to bear.
Grinley and Gillan (2023) stated that addressing quality of life was key to reducing suicidal behaviors. However, it is difficult to address quality of life without first addressing the chronic pain at the root of poor QOL.
Hadi et al. found six themes linking chronic pain with QOL: “interference with physical functioning, interference with professional life, interference with relationships and family life, interference with social life, interference with sleep, and interference with mood.”
At this point, however, it becomes important to distinguish between different types of suicidal behavior. Those who take their lives by suicide are a fraction of those who attempt. Additionally, those who attempt are but a fraction of those with thoughts of suicide.
Dent (2020) explored the role of pain in Joiner’s theory about the acquired capability for suicide. Pain tolerance and fearlessness about death can increase the capacity for suicide. Joiner’s theories also highlight the distinction between those with suicidal ideation and those who act upon those thoughts. Joiner argues that one must develop an acquired capability for suicide to make that step toward action. How does chronic pain affect this equation?
Dent summarized previous research as showing those in chronic pain to be less pain tolerant and more sensitive to pain. This should lessen the risk of suicidal behaviors. Dent, however, makes a point that lower pain tolerance for those with chronic pain may result in greater distress, which could increase the risk of suicidality.
Dent went on to theorize that those with a higher level of pain tolerance would report lesser amounts of chronic pain and, therefore, less distress from chronic pain. In other words, the converse of theories of suicide capacity may not be the same for those experiencing chronic pain. Specifically, high pain tolerance may lower risk, and low pain tolerance heightens risk.
Van Orden et al. (2010) conceptualized the idea that a sense of liability could be a key component of suicidal capacity. They compared this to thinking that “my death is worth more than my life.” Importantly, one of the factors they considered in liability thinking was distress from physical illness.
This may be where quality of life comes into play. Let’s say we have two individuals with chronic pain. One with a high tolerance for pain reports lesser pain burden and, therefore, a likely better quality of life. Versus an individual with a low pain threshold and a decreased quality of life. The key factor of quality of life can explain what appears to be a contradiction of Joiner’s concept of acquired capacity for suicide.
To conclude, we must take quality of life into consideration in suicide prevention efforts. A key component of quality of life is chronic pain. Therefore, as if easing the burden of chronic pain were not enough, we must address chronic pain as if we were addressing suicide prevention.
Thomas Grinley MBA, CMQ/OE, CLYB, is Program Planning and Review Specialist at the New Hampshire Department of Health and Human Services.
References
Balazs J, Miklosi M, Halasz J, Horváth LO, Szentiványi D and Vida P (2018) Suicidal Risk,
Psychopathology, and Quality of Life in a Clinical Population of Adolescents. Front. Psychiatry 9:17. https://doi:10.3389/fpsyt.2018.00017
Berlim, M.T. & Fleck, M.P.A.(2003) Quality of life: A brand new concept for research and practice in psychiatry. Brazilian Journal of Psychiatry, 25(4), 249-252, https://doi.org/10.1590/S1516-44462003000400013
Chen, C., Pettersson, E., Summit, A.G. et al. Chronic pain conditions and risk of suicidal behavior: a 10-year longitudinal co-twin control study. BMC Med 21, 9 (2023). https://doi.org/10.1186/s12916-022-02703-8
Dent, N. A. (2020). The Moderating Role of Pain Tolerance and Fearlessness about Death (The Acquired Capability for Suicide) in the Relationship between Chronic Low Back Pain and Suicidal Behaviour (Doctoral dissertation, Fielding Graduate University).
Hadi MA, McHugh GA, Closs SJ. Impact of Chronic Pain on Patients’ Quality of Life: A Comparative Mixed-Methods Study. J Patient Exp. 2019 Jun;6(2):133-141. doi: 10.1177/2374373518786013. Epub 2018 Jul 5. PMID: 31218259; PMCID: PMC6558939.
Hoefer, Karen, “Quality of Life of Adults Who Have Attempted Suicide” (2020). Electronic Theses and Dissertations. Paper 3684. https://dc.etsu.edu/etd/3684
Kristy Themelis, Jenna L. Gillett, Paige Karadag, Martin D. Cheatle, Nicholas A. Giordano, Shyam Balasubramanian, Swaran P. Singh, Nicole KY Tang, Mental Defeat and Suicidality in Chronic Pain: A Prospective Analysis, The Journal of Pain, Volume 24, Issue 11, 2023,
Pages 2079-2092, ISSN 1526-5900, https://doi.org/10.1016/j.jpain.2023.06.017
Van Orden KA, Witte TK, Cukrowicz KC, Braithwaite SR, Selby EA, Joiner TE Jr. The interpersonal theory of suicide. Psychol Rev. 2010 Apr;117(2):575-600. doi: 10.1037/a0018697. PMID: 20438238; PMCID: PMC3130348.
Wilson KG, Kowal J, Henderson PR, McWilliams LA, Péloquin K. Chronic pain and the interpersonal theory of suicide. Rehabil Psychol. 2013 Feb;58(1):111-115. doi: 10.1037/a0031390. PMID: 23438008; PMCID: PMC3998981.
