Self-perceived burden (SPB) is an empathetic apprehension stimulated by the impact of one’s own illness on others. In easier terms, the idea of being ill and having to be taken care of cause feelings of guilt, becoming a liability, distress and ultimately diminishes one’s sense of self. Various studies have linked SPB with depression, especially among the medically ill and chronic pain patients (CPPs). Since the likelihood of suicide increases with depression, it can be assumed that SPB is also associated with suicidality.

A study recently published by the American Academy of Pain Medicine investigated whether SPB was associated with patients with acute or chronic pain with following five types of suicidality:

  • Active suicide ideation
  • Wish to die
  • History of suicide attempts
  • Preference for death over being disabled
  • Presence of suicide plan

The results demonstrated that both types of patients exhibited some sort of suicidal tendencies, making it essential to consider ways to uplift their self-esteem and reduce their psychological stress.

SPB And Suicidality — What Previous Studies Have Shown

A correlation between SPB and suicidality has been found in a variety of populations, such as adolescents, older adults and Mexican-American women, end of life patients, cancer patients, suicide victims and armed-force veterans.

Limited research has been conducted regarding the association between chronic pain patients (CPPs) and SPB. A recent study analyzed the items on a Patient Health Questionnaire and correlated them with the 10-item SPB scale in CPPs from an interdisciplinary, chronic pain, out-patient self-management program. The highest correlation was seen with suicidal ideation and feelings of worthlessness. Statistical evidence also indicated that SPB was a significant predicator of suicidality.

Methodology Of Current Study: Self Perceived Burden Can Be A Cause Of Suicides

However, previous researchers have not included comparison groups while addressing the issue of suicidality, such as community non-patients without pain (CNPWP) and acute pain patients (APPs). Scientists involved in this study decided to take this approach.

·       Study Participants

Individuals were asked to participate via self-selection. Any individual between the ages of 18 and 65 was allowed to participate and was reimbursed for participation. A total of 2,264 subjects were enrolled consented to participate, and were presented with a data pool of 600 items/questions previously used to develop the Battery for Health Improvement-2 (BHI-2). The latter is a behavioral inventory intended to measure various psychological, psychiatric and somatic complications generally associated with chronic pain.

Out of the 2,264 subjects, 777 were actually patients enrolled in rehabilitation facilities for pain and functional complications. They represented 30 states of the US. Of these 777 subjects, 667 had pain (Numerical Rating Scale [NRS] score greater than zero) and 110 had no pain (CNPWP). Out of the patients with pain, 341 were assigned as having chronic pain (CPPs – pain equal to or greater than 90 days). The remaining 326 were designed as having acute pain (APPs – pain less than 90 days).

The remaining 1,487 were from the general community, of which 1,329 responded ‘No’ to the question ‘Do you have a serious medical condition?’ and were assigned to the community healthy group. The other 158 responded with a ‘Yes’ to the same question and were assigned to the community non-healthy group. These community subjects were recruited from 16 states representing all geographical areas of the US.

·       Rating Pain And Depression

The scale used to rate the pain was anchored at 0 for ‘no pain or discomfort’ and 10 for ‘worst pain or discomfort’. Using this rating, participants were asked to rate the highest average and the lowest average pain they had experienced in the last month, along with the length of time the pain was present.

The BHI-2 consists of a scale called the ‘Vegetative Depression Scale’ for assessment of physical/behavioral symptoms of depression. There are five questions on the data set based on 26 physical symptoms commonly associated with depression, as chosen by 12 psychological experts in pain treatment.

  • Data Analysis

Each response on the data set was scored on a four point Likert scale (disagree, disagree, agree, and strongly agree – assigned scores 0 through 3, respectively). For statistical analysis, these responses were converted into a dichotomy where respondents were categorized as being in favor if they agreed or strongly agreed with a question.

Results – Establishing Various Links

The results can be clearly deciphered considering each study hypothesis separately.

  • Hypothesis No.1 – a greater number of APPs and CPPs should confirm having SPB than CNPWP.

This proved to be true. CPPs were more likely to confirm having SPB as compared to APPs. This corroborates earlier findings that SPB is associated with depression in populations without chronic pain as well, leading to suicidal tendencies. This also shows that SPB is found in APPs but at a lower prevalence as compared to CPPs. It is an extremely rare occurrence in non-painful subjects who consider themselves healthy.

  • Hypothesis No. 2 – SPB should be prevalent at a greater frequency in those CPPs who confirm various forms of suicidality, as opposed to APPs with a similar confirmation.

This was not found to be the case. Similar percentages of CPPs and APPs affirmed having SPB. However, both percentages were high, ranging from 18 percent to 33 percent.

  • Hypothesis No. 3 – after controlling for age, sex, race, education and depression, SPB should be linked to different forms of suicidality in APPs and CPPs.

This was found to be true. In both the cases, after controlling for demographics and depression, SPB was significantly associated with all five forms of suicidality. After controlling for the vegetative depression scale as well, SPB was also significantly associated with nine forms of suicidality in APPs and CPPs.

Due to a low number of participants in the CNWP group who confirmed having SPB, an association could not be performed for the group.

Possible Limitations

Despite achieving statistically significant and potentially relevant results, the study was hindered by certain several factors. These include the following:

  1. Self-selection bias for admission into data pool.
  2. Some APPs and CPPs might have given invalid, overstated, or random information about SPB and suicidality.
  3. Defining criterion for distinction between acute and chronic pain used in the study was ‘pain duration’. Despite being well-accepted in literature, this does not ascertain that the condition is etiologically different, or that the patient knows whether he/she is suffering from acute or chronic pain.
  4. Community subjects were enrolled randomly from the general population via self-selection. They were then enrolled to match the demographics of the general population by race, education, sex and age.
  5. The number of Asian participants was very low. Knowing that significant genetic and cultural differences exist in pain expression, the results of this study might not be applicable to the Asian population.
  6. Only a single item was used to determine SPB, as compared to the 10-item validated SPB scale used in previous studies.
  7. The study was to participants less than 65 years old. Patients older than 65 are more likely to be disabled and feel they are a burden.
  8. It has been established that CPPs have a significant psychiatric comorbidity. However, in our assessments, there are no data indicating psychiatric comorbidity in APPs. Moreover, APPs have never been compared with CPPs for psychiatric comorbidity.

Analysis and Importance of Findings

The novelty of the results lies in the fact that:

  • These findings go beyond simply associating SPB with suicidal ideation. They demonstrate that SPB is also linked to other forms of suicidality.
  • The findings corroborate previous studies and suggest that SPB is important to suicidality in APPs.

The clinical significance of these results can be highlighted as follows:

  • Any APP or CPP feeling that they are a burden should be examined for depression and the presence of suicidality.
  • Early identification of SPB could potentially lead to early identification of suicidal APPs and CPPs. Moreover, early identification could result in a target for treatment – focusing on SPB in individuals, couples and family interventions could potentially help reduce depression and the potential for suicidality in at-risk individuals.
  • Behavioral clinicians should consider conducting routine assessments of SPB among APPs/CPPs during psychiatric/psychological sessions.

There is significant evidence suggesting that the subdivision of suicidality into various subcategories while performing research is of importance:

  • Passive suicidality is common among psychiatric patients and CPPs. Moreover, the belief that disability might lead to passive suicidality is frequently found among CPPs.
  • Active suicide ideation is a major risk factor for suicide completion, especially in the presence of a suicide plan.
  • A history of previous suicide attempts has been linked to repeat suicide attempts and suicide completion.

Hence, subdividing patients according to these subgroups could help in the early identification of those at a greater risk for suicide completion.

In conclusion, the research clearly demonstrates an association between self-perceived burden (SPB) and various forms of suicidality in both acute pain patients (APPs) and chronic pain patients (CPPs). This highlights the need for an initiative of early interventions and regular check-ups for all APPs and CPPs. Moreover, follow-up studies could attempt to decipher whether SPB is linked to suicidality in non-patients without pain, along with exercising efforts to develop a variable predictor model within CPPs for the detection of SPB.