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Suicidal Ideation in Outpatients With Chronic Musculoskeletal Pain: An Exploratory Study of the Role of Sleep Onset Insomnia and Pain Intensity

Smith, Michael T. PhD*; Perlis, Michael L. PhD†‡; Haythornthwaite, Jennifer A. PhD*

Original Article

Objectives Sleep disturbance, depression, and heightened risk of suicide are among the most clinically significant sequelae of chronic pain. While sleep disturbance is associated with suicidality in patients with major depression and is a significant independent predictor of completed suicide in psychiatric patients, it is not known whether sleep disturbance is associated with suicidal behavior in chronic pain. This exploratory study evaluates the importance of insomnia in discriminating suicidal ideation in chronic pain relative to depression severity and other pain-related factors.

Methods Fifty-one outpatients with non-cancer chronic pain were recruited. Subjects completed a pain and sleep survey, the Pittsburgh Sleep Quality Index, the Beck Depression Inventory, and the Multidimensional Pain Inventory. Subjects were classified as “suicidal ideators” or “non-ideators” based on their responses to BDI-Item 9 (Suicide). Bivariate analyses and multivariate discriminant function analyses were conducted.

Results Twenty-four percent reported suicidal ideation (without intent). Suicidal ideators endorsed higher levels of: sleep onset insomnia, pain intensity, medication usage, pain-related interference, affective distress, and depressive symptoms (P < 0.03). These 6 variables were entered into stepwise discriminant function analyses. Two variables predicted group membership: Sleep Onset Insomnia Severity and Pain Intensity, respectively. The discriminant function correctly classified 84.3% of the cases (P < 0.0001).

Discussion Chronic pain patients who self-reported severe and frequent initial insomnia with concomitant daytime dysfunction and high pain intensity were more likely to report passive suicidal ideation, independent from the effects of depression severity. Future research aimed at determining whether sleep disturbance is a modifiable risk factor for suicidal ideation in chronic pain is warranted.

From the *Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland; †Department of Psychiatry, University of Rochester School of Medicine and Dentistry; and ‡Department of Clinical and Social Psychology, University of Rochester, Rochester, New York.

Received for publication January 27, 2002;

revised October 16, 2002; second revision December 7, 2002; accepted December 7, 2002.

Reprints: Michael T. Smith, PhD, Johns Hopkins University, Department of Psychiatry and Behavioral Sciences, 600 North Wolfe Street/Meyer 101, Baltimore, MD 21287 (e-mail:

© 2004 Lippincott Williams & Wilkins, Inc.