Psychological Pain and Suicidality in Patients With Depression

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CASE VIGNETTE

“Ms Hat” is a 52-year-old Caucasian female with a history of recurrent, severe major depressive disorder (MDD) with psychotic features. She presents to the emergency room due to an overdose on an unknown sertraline and ziprasidone. Her mother called an ambulance due to concerns that the overdose was intentional and represented a suicide attempt. Ms Hat says she is not suicidal, but rather wants to “feel happier.”

She has been increasingly depressed in the past year due to the unexpected death of her brother from cardiovascular disease as well as witnessing the death of her beloved dog. She has voiced chronic passive suicidal ideation over the past year without a specific plan or intent. As Ms Hat’s psychiatrist, how would you manage her suicidality?

MDD is associated with an increased risk of suicide,¹ so, identifying risk factors for and predictors of suicide in this patient population is crucial. Psychological pain (psychache) is an important factor in understanding suicide.^2,3

Psychological pain is characterized by intense feelings of shame, humiliation, anguish, despair, loneliness, and dread,⁴ as well as feelings of failure, abandonment, and belief that the pain is irreversible.⁵ Suicide may be viewed as the only means of escaping psychological pain that exceeds an individual’s threshold of tolerance.

Higher levels of psychological pain are associated with increased suicide risk.^6,7 A previous meta-analysis explored the impact of psychological pain in suicide,⁸ but the role of depression in this relationship remains unclear.

The Current Study

Wang and colleagues⁹ performed a meta-analysis of the relationship between psychological pain and suicidality in MDD. The investigators systematically searched PubMed, Web of Science, and PsyINFO according to PRISMA guidelines. The protocol was registered in PROSPERO (CRD42023416018).

Inclusion criteria were studies in English; studies with participants who had been diagnosed with MDD according to DSM or ICD criteria; empirical papers with quantitative research; studies in which psychological pain is clearly defined and measured with a standardized instrument; studies that assessed suicidality; and studies that quantified the association between psychological pain and suicidality. Exclusion criteria were studies that lacked data on psychological pain or measured psychological pain using a non-validated scale.

Two authors independently assessed the studies, extracted the data, and assessed study quality. Data were analyzed using a random effects meta-analysis model. Risk of bias was assessed using funnel plots and Egger’s test.

Seven papers, comprising 1364 participants, met the inclusion/exclusion criteria. Across all studies, psychological pain was associated with a significant increased odds of suicidality in patients with MDD (OR=1.32). Between-study heterogeneity was high. The association between psychological pain and suicidality was significantly moderated by (older) age, but not gender.

Egger’s test was significant for potential publication bias. However, in post-hoc analyses, the association between psychological pain and suicidality remained significant in both “leave one out” meta-analysis (ORs=1.18-1.69) and the Duval and Tweedie trim-and-fill method (OR=1.20).

Study Conclusions

The investigators concluded that psychological pain was associated with increased odds of suicidality in MDD. This association was moderated by older age, but not gender. Between-study heterogeneity was significant, and there was evidence of potential publication bias, but the association remained significant in post-hoc analyses.

Study strengths include the large cumulative sample size. Study limitations include heterogeneity in scales used to assess psychological pain, the definition of suicidality, and the cross-sectional design of included studies.

The Bottom Line

Psychological pain is associated with increased odds of suicidality with MDD, particularly in the elderly. Psychological pain is an important treatment target in this patient population toward suicide prevention.

Dr Miller is a professor in the Department of Psychiatry and Health Behavior at Augusta University in Georgia. He is on the Editorial Board and serves as the schizophrenia section chief for Psychiatric Times®. The author reports that he receives research support from Augusta University, the National Institute of Mental Health, and the Stanley Medical Research Institute.

References

1. Heuschen CBBCM, Mocking RJT, Zantvoord JB, et al. Suicidal ideation in remitted major depressive disorder predicts recurrence. J Psychiatr Res. 2022;151:65-72.

2. Mee S, Bunney BG, Bunney WE, et al. Assessment of psychological pain in major depressive episodes. J Psychiatr Res. 2011;45(11):1504-1510.

3. Shneidman ES. Suicide as psychache. J Nerv Ment Dis. 1993;181(3):145-147.

4. Shneidman ES. Perspectives on suicidology. Further reflections on suicide and psychache. Suicide Life Threat Behav. 1998;28(3):245-250.

5. Orbach I, Mikulincer M, Sirota P, Gilboa-Schechtman E. Mental pain: a multidimensional operationalization and definition. Suicide Life Threat Behav. 2003;33(3):219-230.

6. Chen S, Cheng Y, Zhao W, Zhang Y. Psychological pain in depressive disorder: a concept analysis. J Clin Nurs. 2023;32(13-14):4128-4143.

7. Levi-Belz Y, Gvion Y, Grisaru S, Apter A. When the pain becomes unbearable: case-control study of mental pain characteristics among medically serious suicide attempters. Arch Suicide Res. 2018;22(3):380-393.

8. Ducasse D, Holden RR, Boyer L, et al. Psychological pain in suicidality: a meta-analysis. J Clin Psychiatry. 2018;79(3):16r10732.

9. Wang T, Yang L, Yang L, et al. The relationship between psychological pain and suicidality in patients with major depressive disorder: a meta-analysis. J Affect Disord. 2024;346:115-121.