Chapter no 2

Review of literature

There is a clear relationship between suicide risk and chronic pain conditions. However, the
exact nature of this link has been poorly understood, with risk attribution often limited to
comorbid depression. Perceived burdensomeness has already been confirmed as a risk factor for
suicidal ideation (SI) and suicide attempt in the general population. Self-perceived burden,
studied among medically and terminally ill medical populations, has begun to receive a great
deal of attention as a suicide risk factor. However, this risk has not been considered in an
outpatient chronic pain population, a group likely to experience perceived burdensomeness as a
particular problem. Guidelines recommend routine suicide risk screening in medical settings, but
many questionnaires are time-consuming and do not allow for the assessment of the presence of
newly identified risk constructs, such as perceived burdensomeness. This retrospective study
examined the relationship between depression, perceived burdensomeness, and SI in a patient
sample seeking behavioral treatment for chronic pain management. A logistic regression model
was developed, with preliminary results indicating perceived burdensomeness was the sole
predictor of SI, even in the presence of other well-established risk factors such as age, gender,
depressive symptoms, and pain severity. Findings highlight the potential utility of a single-item
screening question in routine clinical care as an incrementally superior predictor of SI in a
chronic pain population. (Sherker, J., & Sherry, D. D, 2018)

The rates of suicidal ideation and completed suicide among adolescents

have become increasingly alarming in recent years. Epidemiological studies indicate that a large
portion of adolescents suffer from chronic pain, which research supports as a risk factor for
suicidal ideation and behaviors. Further, psychological factors may account for the associations
between chronic pain and suicidality. The current study sought to fill gaps in the literature on
chronic pain and suicidality in adolescents, by examining whether depression mediates the links
between various chronic amplified pain symptoms and suicidal ideation. Retrospective medical
record reviews were conducted of 453 adolescents ages 11–17 (M = 14.34, SD = 1.83), who
presented to a tertiary pain clinic and received a diagnosis of amplified pain. Prior to their initial
appointment, participants completed measures assessing pain symptoms, disability, depression,
and suicidality. We found pain duration was significantly related to suicidal ideation, however,
this association was mediated by depressive symptoms. These results highlight the need for early
screening and intervention for depressive symptoms among adolescents suffering from amplified
pain. Clinical recommendations for mental health and medical providers are discussed. A study
investigated a potential mediating role of depression between level of pain intensity and suicidal
ideation of people who are in chronic pain from nonmalignant illnesses. Participants in this study
were 248 patients seeking treatment for chronic pain at the pain center of a university hospital in
Korea. Structural equation analyses showed that only the original full mediation model had
adequate goodness-of-fit indices for suicidal ideation. Bootstrapping procedures we performed
on the original full mediation model yielded a significant mediation effect of depression on
suicidal ideation. The findings suggested that intense pain may lead to elevated rates of
depression, thereby contributing to an increase in suicidal ideation, rather than playing a role as a
direct contributing factor for greater suicidal ideation among people in chronic pain. (Smit et al.,
2006).

Suicidal ideation among individuals suffering from chronically

painful conditions has not been widely studied, although rates of completed suicide are believed
to be elevated in this population relative to the general population. The psychiatric literature on
suicide documents the importance of controlling for the severity of depression when studying
factors associated with suicidal ideation, attempts, or completion. The present study examined
the relationships between suicidal ideation and the experience of pain, pain-related disability, and
pain coping efforts among a sample of individuals experiencing chronically painful conditions.
Of 200 patients evaluated on an inpatient rehabilitation unit in a psychiatric service, 13
individuals (6.5%) reported suicidal intent on a commonly used self-report measure of symptoms
of depression, the Beck Depression Inventory. This group was compared to a matched (age, sex,
pain duration) group of similarly depressed individuals (N=13) and a matched group of non-
depressed individuals (N=13) on measures of pain, disability, pain beliefs, and pain coping
strategies. A history of a suicide attempt was associated with suicidal intent. Family history of
substance abuse was significantly more prevalent among the depressed groups, regardless of
suicidal thinking. The depressed/suicidal group and depressed/non-suicidal groups reported
higher levels of pain, higher levels of pain-related disability, lower use of active coping, and
higher use of passive coping compared to the non-depressed group. The depressed groups did not
differ from one another on any of the measures of pain experience. Depression, not suicidal
status, consistently predicted level of functioning. The prevalence of suicidal intent was
comparable to rates observed in other studies and relatively low. When individuals with chronic
pain report suicidal intent, it is imperative that measures preventing self-harm be implemented
immediately and the patient's depression be treated aggressively.( Murray and Lopex, 1997)

Depressive and anxiety disorders are common at all ages. In addition, their
effects on well-being and daily functioning are enormous and comparable to those of major
chronic physical illnesses (Buist-Bouwman et al., 2006). In economic terms, the cost of
depressive and anxiety disorders due to loss of productivity and use of health services ranks
among the top-five of all disorders (Smit et al., 2006). Consequently, depressive and anxiety
disorders are relevant candidates for efforts to improve public health. During the past decades,
progress has been made in the development and testing of different forms of treatment for
depressive and anxiety disorders. Although successful treatment is available, a large proportion
of those affected remains undiagnosed and untreated (Bijl and Ravelli, 2000), and treatment is
not effective for everyone. Moreover, although it is firmly established that the duration of
episodes can be influenced with treatment, it is uncertain whether treatment has effect on the
long-term course of depressive or anxiety disorders. The extremely variable natural history
precludes matching interventions accurately to those who are most in need of treatment. This is
reflected in current professional treatment guidelines which offer little guidance as to which
patients may recover without substantial treatment and which patients may be in need of more
intensive interventions. A first requirement for a more accurate matching of limited treatment
resources to the projected need of patients is to have detailed knowledge of the factors that
determine or predict the prognosis. For this, data on (determinants of) the long-term course and
consequences of anxiety and depressive disorders are essential. Suicidal behaviors present
significant challenges to individuals, families, and public health systems. In the year 2000 alone,
a suicide was attempted every 3 s and completed every 40 s, resulting in about a million deaths
worldwide. More than a half of all suicides are committed by persons younger than 45 years of
age. Gender differences have been documented in the rates of suicide attempts and completions,
levels of suicidal intent and lethality, choice of method of suicide, and suicidal ideation. To
identify studies for this review, PsycINFO (Ovid) and MEDLINE (Ovid) database articles
published since 1985 and 1977, respectively, were compiled using the following, personality,
personality correlates, or personality traits; and, suicide attempts, suicide, suicidal ideation, or
suicidal behavior. These articles were complemented by additional material identified by
scanning reference lists of relevant publications. A single reviewer (J.B.) selected articles on the
basis of the following inclusion criteria, the study included at least one of the following suicidal
outcomes: ideation, attempts, or completion; the study used standardized personality instruments,
the work was considered original research; the paper was published in English.

Evidence with regard to the role of impulsivity is generally supportive. With the
exception of four studies this trait was shown to be positively associated with attempt history in
diverse populations, in those with psychiatric diseases including major depression and gambling
problems and in those with less lethal suicide attempts. A similar trait, novelty seeking,
measured at age 16, was also important in predicting future risk of attempts in young adults.
Relatedly, impulsive aggression – as measured by the Brown Goodwin Inventory of Aggression
was shown to be significantly associated with attempts in psychiatric patients. Indirect, verbal,
general and lifetime aggression measures were typically higher in attempters relative to the non-
attempting controls in diverse samples. Hopelessness, on the other hand, was not significantly
different between controls and depressed attempters with mild traumatic brain injury attempters
with other psychiatric conditions, and prison inmates. Furthermore, whether or not hopelessness
can differentiate between first and multiple attempters is unclear. Similarly, evidence in younger
individuals is inconclusive. Findings of positive correlation with attempts in teenage girls and
hospitalized adolescents and in Zuni American Indian adolescents are in contrast with a report of
a non-significant association in hospitalized children. Nevertheless, in adults, the positive
association of hopelessness and attempts is replicated more consistently.

In a study of 18 to 40-year-old male suicide completers with

major depression who were compared to non-suicidal living controls hospitalized for the same
diagnosis, proxy assessments indicated higher prevalence of extreme impulsivity (45.5 vs. 8%,
v2 ¼ 9.63, d.f. ¼ 1, t ¼ 0.002) and total lifetime aggressivity (33.3 vs. 18.72%, t ¼ 2.424, d.f. ¼
24, P ¼ 0.001) (40). Furthermore, the same Brown–Goodwin-derived measure of aggressivity
was associated with violent suicide method and with adolescent completions. In addition,
Freiburg-personality-inventory-derived aggressiveness facets – spontaneous and reactive
aggressivity and excitability – were significantly different between male completers and controls
Relatedly, a Buss–Durkee-scale-derived measure of hostility demonstrated that completers, with
no Axis I diagnosis, scored significantly higher on several hostility components – irritability,
resentment and guilt – compared to healthy, living controls. The identification of theoretically
and empirically supported correlates of suicide ideation is important to improve treatment
approaches to suicide. This study sought to examine the association between interpersonal trust
(theoretically conceptualized as a distal risk marker) and suicide ideation in adolescence.
Specifically, it was hypothesized that interpersonal trust would be negatively associated with
suicide ideation via perceived burdensomeness and thwarted belongingness (conceptualized as
more proximal risk markers). Data were drawn from a cross-sectional sample of 387 adolescent
inpatients between the ages of 12 and 17 years (M = 14.72, SD = 1.49). The sample was 63.6%
female, 37.5% Hispanic, 26.9% African American/Black, and 25.8% Caucasian. Adolescents
completed a series of self-report measures to assess thwarted belongingness, perceived
burdensomeness, interpersonal trust, depressive symptoms, and suicide ideation. A structural
equation model was fit to the data, and results demonstrated a significant indirect path from
interpersonal trust to suicide ideation via perceived burdensomeness, but not thwarted
belongingness. Results suggest that interpersonal trust may be a distal risk marker for suicide
ideation and that interventions to increase interpersonal trust may help prevent the development
of thwarted belongingness, perceived burdensomeness, and suicide ideation. (RYAN M. HILL ,
2018)

The interpersonal–psychological theory of suicide (IPTS; Joiner,

2005; Van Orden et al., 2010) has received considerable empirical support among adolescent
samples (e.g., Hill & Pettit, 2014; Stewart, Eaddy, Horton, Hughes, & Kennard, 2015) and
provides a framework for conceptualizing and organizing correlates of suicide risk. The IPTS
proposes that suicide ideation results from the presence of perceived burdensomeness,
conceptualized as the belief that one has become a burden or drain on the resources of others,
and thwarted belongingness, comprised of a sense of loneliness and perceived lack of reciprocal
care (Joiner, 2005; Van Orden et al., 2010). According to the IPTS, perceived burdensomeness
and thwarted belongingness act as proximal risk factors through which other, more distal risk
markers exert their influence on suicide ideation. Recent data support this position, as perceived
burdensomeness and thwarted belongingness mediate the association between risk markers such
as stress, relatedness, competence, and autonomy and suicide ideation (Buitron et al., 2016) Hill
& Pettit, 2013; Tucker & Wingate, 2014). Given the proximal nature of perceived
burdensomeness and thwarted belongingness, identifying other factors associated with these
IPTS constructs may provide additional targets for interventions to prevent suicide ideation.

Empirical research also supports the idea of trust early in life has been prospectively linked with
later psychosocial functioning in adolescents (Malti, Averdijk, Ribeaud, Rotenberg, & Eisner,
2013); cross-sectionally, interpersonal trust has been positively associated with healthy
relationships (Simpson, 2007), academic achievement, and social competence (Wentzel, 1991),
and negatively associated with depressive symptoms (Lester & Gatto, 1990). Rotenberg et al.
(2005) proposed that trust beliefs comprise three bases: reliability, emotional trust, and honesty.
Reliability refers to the belief that others will “keep their word,” emotional trust refers to the
belief that others will refrain from causing emotional harm (e.g., by keeping confidentiality), and
honesty refers to the belief that others will tell the truth and act with benevolent intent
(Rotenberg et al., 2005). Research utilizing this interpersonal trust framework indicates that
maladaptive interpersonal trust beliefs are associated with lower peer acceptance and greater
aggression, social nonengagement, peer rejection, loneliness, depressive symptoms, and anxiety
(Rotenberg et al., 2014). This is particularly relevant for adolescents as longitudinal studies have
shown that maladaptive attachment relationships in infancy lead to particular risk for social
maladaptation during adolescence (Doyle & Cicchetti, 2017). Specifically, adolescence marks a
crucial period in which biological, psychological, and social development take place in the
context of developmentally salient social tasks (Steinberg et al., 2006). Therefore, disrupted
interpersonal trust resulting from early attachment relationships may lead to heightened risk for a
range of negative psychosocial outcomes in adolescence, particularly those involving
interpersonal relationships.

Although it has yet to be tested, interpersonal trust may also be associated

with thwarted belongingness and perceived burdensomeness. Rotenberg (1994) proposed that
individuals with low trust are less willing (Hill et al., 2019) to initiate contact or share personal
information with others, which serves to maintain loneliness and poor social support. The
empirical literature also supports an association between interpersonal trust beliefs and
loneliness, the number of friendships youth have, and social disengagement (e.g., Parker &
Asher, 1993) Rotenberg et al., 2010). Taken together, evidence suggests that interpersonal trust
beliefs are conceptually linked with aspects of thwarted belongingness, including loneliness,
poor social support, and social disengagement. A study evaluated associations between
interpersonal trust, thwarted belongingness, perceived burdensomeness, and suicide ideation in
adolescents. Results indicated support for an indirect effects model in which interpersonal trust
was associated with suicide ideation via its association with perceived burdensomeness. These
results identify interpersonal trust as a potential factor in the development of thwarted
belongingness and perceived burdensomeness and as a potential target for early interventions
aimed at preventing suicide ideation. Future research should further evaluate the role of
interpersonal trust in the development of thwarted belongingness and perceived burdensomeness
and evaluate potential mechanisms for modifying interpersonal trust.

A similar analysis was conducted in which depressive

symptoms were not included as a covariate. Indices of model fit were evaluated and uniformly
pointed toward good model fit, Results showed that the point estimates and 95% confidence
intervals for each of the unstandardized path coefficients in the model. The model predicted
10.2% of the variance in thwarted belongingness, 11.0% of the variance in perceived
burdensomeness, and 44.9% of the variance in suicide ideation. The indirect path via perceived
burdensomeness was statistically significant, but the indirect path via thwarted belongingness
was not significant. For the path from interpersonal trust to suicide ideation via perceived
burdensomeness, the model suggests that a 1-point increase in interpersonal trust was associated
with a 0.70-point decrease in suicide ideation score. An additional model was examined, in
which a direct path from interpersonal trust to suicide ideation was added. A Satorra- Bentler
chi-squared difference test for nested models revealed the models did not significantly differ in
appropriateness of fit. Thus, the simpler model without the direct path from interpersonal trust to
suicide ideation was retained. (Rotenberg et al., 2010).

Several studies demonstrated that hostility may also be

relevant to the risk of suicide attempts. In fact, very specific temporal interactions involving
three of its components guilt, resentment, and verbal aggression correlate strongly with plans or
act of suicide (, Di Muro A, 1998). Moreover, Brent and colleagues have shown it to be higher in
mood-disordered attempters with siblings concordant for suicidal behaviors. Hostility also
predicted early attempts in the offspring of the former group. Several lines of evidence suggest
that trait anger may be important in the risk of attempts. While it was not found to be significant
in adult patients, admitted for having attempted suicide, it did correlate with the number of
attempts and previous history of attempts in adolescents and in women. Often considered a facet
of anger, irritability, and inward irritability, in particular, may be relevant in both clinical and
non-clinical samples. Lastly, cognitive traits, such as self-criticism and perceptual aberration,
may be relevant for the risk of attempts but require independent confirmation, as does the
preliminary evidence implicating anhedonia, modesty, dependency, unconventionality, social
desirabilit and inadequacy, and defensiveness. One of the most prominent correlates of suicidal
ideation is hopelessness, although its importance may vary across age groups. Its correlation with
suicidal thoughts, for example, may be stronger in undergraduate students and postgraduate
female students than in children. Nevertheless, in adolescence and adulthood, it was found to be
a significant predictor in regression models of suicidal ideation. Path analyses, furthermore,
suggest that baseline and 6-month hopelessness have direct paths to 6-month suicidal ideation.
Hopelessness may also be involved as a mediator, contributing to the relationships of cognitive
bias, stress, and/ or problem-solving with suicidal ideation. (Dixon WA, Rumford KG, 1992) .

They imply that there is a climax to a stage where suicide attempt or

completion becomes almost inevitable (Kelleher, personal communication 1998). This
assumption is flawed because many people who become actively suicidal never make an attempt,
as indicated in the study by Mishara, Baker & Mishara (1976). Alternatively, cases of impulsive
suicidal behavior, particularly in young people, do not usually involve a build-up in suicide
intent. (Hoberman & Garfinkel 1988) have found that in a sample of 229 youth suicides only
28% evidenced a plan to commit suicide and this was usually of brief duration. Definite
preparation for death was apparent in only 8% of suicides. Suicide intent is a key factor in
conversion as it has been associated with outcome in both suicide and attempted suicide (Beck,
Schuyler & Herman, 1974). As described earlier it has been used to distinguish those attempters
who eventually commit suicide from those who do not. Although suicide attempters and suicides
are two separate and distinct groups (Kelleher et al., 1999; Roy, 1991) they do overlap to some
extent. Among suicide attempters, those who actually go on to commit suicide have been found
to be most similar, in terms of hopelessness and depression measures, to those expressing high
suicide intent (Lester, Beck & Mitchell 1979; Linehan 1987).
 Almost 10% of patients
reported a wish to be dead, and 5.5% reported active suicidal ideation. The presence of a death
wish was associated with significantly higher depression (CRSD) scores and self-rated measures
of psoriasis severity. The significance of the comorbidity between depression and psoriasis is
difficult to interpret, because the data in this study is from a onetime cross-sectional survey. It is
possible that our patients were premorbid depressed, and this predisposed them to developing
more severe psoriasis. Alternately, having to cope with psoriasis could have resulted in a
depressive reaction among the patients. The clinical significance of the correlations also has to
be interpreted in light of our finding that, for example, the correlation coefficient between
depression and global severity indicates that depression accounted for only 15% of the variance
in the global severity. As is to be expected, a majority of the variance in psoriasis severity was
most likely determined by non-psychiatric factors. The literature on depression in medical
disorders'' has tended to focus upon life threatening illnesses such as malignancies,
cardiovascular disease, and end-stage renal disease and essentially ignores non-malignant
diseases of the skin. Generally, fatal and life-threatening medical disorders have been associated
with severe depression, which is usually associated with suicidal ideation.'' To our knowledge,
only one study has evaluated the presence of suicide risk among patients with a non-malignant
skin disorder, i.e., Darier's disease associated with marked cosmetic disfigurement. In surveys of
suicidal ideation among the general population, 7% to 10%' of patients wished that they were
dead and life was not worth living at some time over the previous 1 year and over their lifetime^
respectively. A percentage of patients (3.9% to 2.5%') reported having serious suicidal thoughts
at some time over the previous 1 year and over their lifetime respectively. In comparison to these
Canadian and British' studies, there was a higher point prevalence of suicidal ideation among our
psoriasis patients. Future studies require a more demographically matched control population.
Our findings are also in contrast with reports that severe depression and suicidal ideation are
mainly a feature of life-threatening medical disorders. The clinician should be aware of the
comorbidity between depressive symptoms, suicidal ideation, and psoriasis severity, as this can
have important implications in the overall management of psoriasis.

Hypothesis: by taking the previous literature in consideration following hypothesis are

developed,
H1: there is a positive correlation between pain and depression.

H2: there exist a positive correlation between pain depression and suicide ideation.

H3: depression has a mediating role in the relationship of chronic pain and suicide ideation.