The finding:
The study found that individuals experiencing physical pain are significantly more likely to have suicidal thoughts, attempts, and deaths compared to those without pain. The strongest associations were observed for lifetime death wish, current suicidal ideation, and lifetime suicide attempts. Adolescents with pain exhibited higher rates of self-harm, while adults had an increased risk of suicide attempts and deaths, and older adults were more prone to suicidal ideation. Women with pain were more likely to experience suicidal ideation than men, and specific pain conditions like fibromyalgia, abdominal pain, and migraines showed a particularly strong link to suicide risk. However, the study noted high variability across included studies, and some suicide-related outcomes lacked sufficient data. Despite these limitations, the findings highlight physical pain as a significant risk factor for suicidality, reinforcing the need for integrated pain and mental health management.

Strength and weaknesses:
The study’s strengths lie in its comprehensive scope, analyzing 91 studies across different age groups and pain conditions, providing robust evidence on the link between physical pain and suicidality. It follows rigorous methodologies, adhering to PRISMA guidelines and employing a strong statistical approach with meta-analysis software. The study highlights key risk factors, such as gender differences, pain severity, and specific conditions (e.g., migraines, fibromyalgia), offering valuable insights for suicide prevention. Additionally, its public health relevance is significant, emphasizing the need for integrated pain and mental health care. However, the study has limitations, including high heterogeneity, as the included studies vary in design, sample populations, and measurement methods, affecting consistency. The reliance on cross-sectional and retrospective data limits the ability to establish causation, and some suicide-related outcomes lack sufficient research. There is also a potential publication bias, as studies showing positive associations may be overrepresented. Furthermore, confounding factors such as psychiatric comorbidities and pain management strategies are not consistently controlled across studies. Lastly, focus on odds ratio only without relative risk or hazard ratio limits interpretation of risk over time and of the practical meaning of the results.

Relevance:
This meta-analysis provides an update from the last meta-analysis on this topic from 2015, which appears to have been greatly needed as the authors point out that the number of studies on the pain-suicide link have substantially increased. While we often hear about pain in the context of the opioid epidemic, suicidal behavior as a consequence of pain is a less flashy topic, and more research may help raise awareness of the critical role of pain in suicidality. As C-L psychiatrists, we are often called in when pain exceeds what primary teams may perceive as acceptable for any given condition, and we are perfectly poised to conduct a risk assessment for these patients whose emotional experience may be overshadowed by their team’s perception of their behaviors. These results make a case for including pain in suicide risk assessments, particularly in high-risk groups such as women, older adults, and those with conditions like fibromyalgia or migraines. As more research comes out showing the benefit of traditional psychiatric treatments for pain and some pain treatments improving mental health (ketamine, acupuncture), the interconnectedness of pain and suicide adds to the argument for more integration of pain management and psychiatric care.