January 21, 2022

Chronic Illness, A Factor in Suicide Risk

By Meghan Bellamy

 

In recent years CDC Statistics have reflected that eight of the top ten causes of death in the US were chronic illnesses, with the tenth being suicide. In 2020, that changed with the insertion of Covid pandemic deaths ranking third, yet chronic disease and suicide remain prominent causes of death in the US.

Chronic illness follows a different course for everyone and often occurs in combinations (comorbidity), and is itself associated with higher risk of suicide. And while the suicide statistics most quoted are deaths, suicidal thoughts (ideation) and attempts represent suffering, often chronic and ongoing, in far greater numbers. These statistics prompted a deeper dive into ways certain biological factors may affect mental wellbeing and suicide risk.

One explanation for increased suicide risk with chronic disease is that receiving an ‘unlivable’ diagnosis or the challenges of living with a chronic illness causes a mental state of depression or hopelessness. Indeed, a recent study indicates that risk of suicide doubles in the first year after a cancer diagnosis and varies with cancer type, however, it is important to note that risk reduces and stabilizes as time goes on. A growing insight suggests that connections to mental distress may not be as simple as depression or pure hopelessness about the dire straits of one’s chronic illness. 

Co-occurrence/co-morbidity of mental health conditions with a chronic condition can be a factor, especially since the first diagnosis a patient receives is often the one that drives assessment, intervention, and care. Traditional Western medicine approaches to treating conditions separately, rather than approaching a patient holistically, often leaves relevant factors and features of a patient’s concerns and overall wellbeing unaddressed. Physical concerns and treatment potential may not be factored into mental health, and vice versa. Clinical tendencies towards ‘diagnostic overshadowing’ often miss the bidirectional nature of co-occurring conditions and the opportunity for greater therapeutic success from a combined approach to care. For example, elevated risk of suicide is evident in people with epilepsy as outlined in this meta-analysis and on the Epilepsy Foundation website. As outlined in this opinion piece, greater consideration of psychiatric conditions and medication use is an area that would benefit from additional research and protocols. Just as a mental health professional may not notice or address a gastrointestinal disorder in the context of a mood disorder, a gastroenterologist treating IBD may not consider referring a patient for anxiety or depression evaluation or treatment, despite associations that have been described.

There is evidence that disease matters in mental health and cognition, the number of chronic conditions and suicide risk both increase with age, and access to healthcare and treatment for both physical and mental concerns can make a difference in outcomes. Chronic illness and related symptoms and factors, such as immune system activation, pain, gut function, inflammation, sleep, medications, cognitive effects, and mobility, may place individuals at higher risk for suicidal thoughts and/or actions. As this paper from the founders of the Zero Suicide initiative shows, a review of health records revealed 17 major physical health conditions that associated with suicides, and three (Traumatic Brain Injury, sleep disorders, and HIV) doubled the risk.

Since JKBF’s focus is on understanding biological factors that contribute to suicidal behaviors, it seems relevant to explore the potential biological components of chronic illness in addition to the social-emotional context that is usually considered. In contemplating paths to prevention, it is important to consider overlaps between suicide and chronic illness, especially factors that are perhaps modifiable and offering potential new tools to reducing suffering and suicide risk.

Pain

Many chronic illnesses are accompanied by pain, a factor that doubles risk of suicidal thoughts and behaviors. Severity and consistency of pain, as well as diagnostic ambiguity, have been reported to increase this risk. Indeed, one of the least understood and ambiguous pain conditions, fibromyalgia, has a risk of death by suicide that has been reported to be ten times that of the general population. Validating and addressing that pain is essential to a patient’s resilience, as this study highlights that risk is reduced when the patient is receiving ongoing and consistent medical care.

Recent reporting on a survey from Mental Health America shows that chronic pain conditions such as arthritis and self-reported moderate to severe mental health concerns often co-exist (79% of respondents). These conditions are bi-directional and often amplify each other. Highlighting the need for healthcare consideration of the whole patient is that 40% of respondents had never been professionally diagnosed with a mental health condition, and many were not receiving treatment. Since mental health conditions and pain each raise suicide risk, is this risk compounded when these conditions co-occur?

Furthermore, the pain that often accompanies chronic disease, whether it be muscular pain, nerve pain, joint pain, or any other, can cause sleepless and restless nights. What’s worse, is that the pain response, the amount of pain a person feels, can often be aggravated by lack of sleep indicating that treatment of sleep conditions may be a way to manage pain and reduce patient distress.

Sleep

Sleep plays an integral role in mental health and overall biological harmony, and when anything gets in the way of sleep patterns, our bodies and minds suffer. Chronic illness and its treatments can directly and indirectly have extremely harmful effects on sleep, which may in turn raise an individual’s risk for mental health problems, increased pain perception, or even suicidality.

Sleep disruption can also substantially increase other symptoms of chronic Illnesses and evidence that it may increase seizures in epileptic patients, blood pressure in cardiovascular patients, and abdominal pain in patients with gastrointestinal disease may result in dangerous feedback loops for overall health. Dr. McCall, in Psychiatric Times, writes that the psychobiology of insomnia suggests that chronic sleep disturbance can be understood as a state of hyperarousal, consistent with the clinical findings that there is a greater risk of suicide in those who are anxious, agitated, or activated. He highlights a risk associated with nightmares in particular, and adds that there is a known link between sleep, chronic illness, and suicide. In some cases, he suggests, the psychobiological effects of unhealthy sleep patterns can be “the straw that breaks the camel’s back” in patients with chronic illness.

Treatment of a chronic illness can also affect sleep patterns as many medications affect sleep patterns. In some cases, medications can aggravate or be the cause of mental health problems, possibly through effects on sleep, as well as on the immune response and the microbiome (which also may impact sleep). In addition, some medications, such as beta-blockers used to treat high blood pressure, have a side effect of nightmares as well as other central nervous system effects.

Certain populations may be more susceptible to sleep disturbance, such as the elderly, who often have multiple chronic conditions, multiple medications, and high suicide rates. As highlighted by the pandemic and increasing awareness around racial tensions, in BIPOC communities sleep may be affected by multiple factors. Sleep and other social determinants of health factor into both physical and mental health concerns, as outlined in this mainstream news piece showing that middle aged black adults have significantly higher incident rates of heart conditions, hypertension, and high blood pressure than their white peers.

Oxygenation

Individuals who suffer from diabetes, obesity, cardiovascular disease, and allergies are more likely to also experience sleep apnea, a disorder that causes the muscles in the airway to relax during sleep, thus momentarily cutting off respiratory function. A primary symptom of sleep apnea is consistently waking up exhausted. When sleep is so frequently disrupted, there is a detriment to cognitive function and problem-solving ability as described in this meta-analysis.  Apnea also results in decreased blood oxygen levels, which over time can result in neurological and psychological detriments such as stroke, depression, and hyperactivity.

Similarly, many patients living with respiratory concerns such as COPD experience chronic hypoxia, or oxygen deficiency. A population-based study published in 2019 found a correlation between chronic hypoxia and suicide risk, especially as oxygen-depleting effects of COPD, high altitude, and/or smoking were combined.  Disruptions to cellular function through oxygenation, metabolism, and energy have effects on functionality of both body and mind.

Immune activation and Inflammation

Chronic disease states often involve some sort of immune response, and inflammation is a hot topic across almost all health conditions, whether they are predominantly viewed as physical or mental. Consideration of the influence of inflammation and immune activation is gaining attention in suicide research, as well as in mental illness. Ongoing inflammation that affects functional neurological and hormonal pathways has been recognized in psychosocial considerations such as childhood trauma, but is also a remarkable feature in many chronic conditions, including traumatic brain injury, cardiovascular disease, arthritis, and multiple sclerosis.

Gut Health

Gut health is getting its day in the sun. Emerging research is linking many previously unanswered questions back to the gut microbiome. As it turns out, our gut plays a role not just in digestion, but also immunity, neurological function, and mood. So, does an unhealthy gut mean an unhealthy mood? Well, it might and according to the National Institute of Diabetes and Digestive and Kidney Diseases, 60-70 million Americans are living with a gut disease of some kind.

Function of the Vagus Nerve, an essential feature of the gut-brain axis and important in the stress response, is reduced in the presence of gut, and perhaps broader, inflammation. Low vagal tone has been associated with poor emotional and attentional regulation, and has been conceptualized as a marker for sensitivity to stress. In yet another example of a bi-directional pathway, this study points to greater risks of anxiety and depression in those with chronic GI disease.

Addiction and Medications

Last but certainly not least, it’s important to address the comorbidity of chronic illness and addiction—an unfortunately common and dangerous occurrence. As HHS outlines, a variety of indicators point to a role of substance use in suicidal behaviors.

First, it’s important to conceptualize addiction itself as a chronic disease. The National Institute on Drug Abuse states that “Addiction is a chronic disease similar to other chronic diseases such as type II diabetes, cancer, and cardiovascular disease.” In many cases of comorbidity, one chronic condition has been caused or aggravated by the other. In the case of substance abuse, there are frequently resultant cases of liver or kidney disease or failure, and certain forms of cancer can be caused by overuse of drugs or alcohol over an extended period of time. Similarly, the effects of a chronic physical illness (e.g., pain) can foster self-medication and overuse of both prescribed and illicit substances. Yes, this is another bi-directional concern.

As mentioned earlier, medications play an integral role in treating chronic illness and related symptoms, yet their misuse shows that prescription drug addiction is an increasing problem in America. Considering the addictive features, as well as the side effect profiles of medications is essential.

Even without abuse or addiction, medications may alter biological balance and functions of the body ranging from sleep to gut health to energy levels that in turn, affect mental health and psychological regulation.

Take Away Message

Many biological mechanisms involved in chronic illness can throw the body and mind out of harmony, and, as described in this paper on hypothyroidism and mania, progress often occurs only when the breadth of underlying features is addressed. In many cases living with chronic illness is, by nature, living without consistent biological harmony and supporting resilience often requires roles for both medical and mental health supports.

From a psychobiological standpoint, the brain is sensitive to shifts in function and energy, and that is when things like depression, restlessness, and other behavioral changes may take effect. Physician, patient, and family member awareness of and communications around the variety of effects of physical conditions and treatments on a patient’s mental health is key.

Although this article only covered a few biological mechanisms and disease states, the take away message is that biological shifts or imbalances can occur in numerous ways and may affect our arousal, moods, and thought processes. As such, chronic illness, often challenging to live with, may contribute to suicide risk in a variety of ways. Awareness of these connections across disciplines suggests mental health providers should consider physical factors that may be influencing their patients, and conversely, as the MHA report on chronic pain suggests, patients receiving treatments for chronic disease should be provided with screenings and supports for mental health concerns.  Treatment of the whole patient may not result in an end to disease, and yet may assist in efforts to reduce suffering, improve quality of life, and hopefully reduce acts of desperation that result in lives lost too soon.

Meghan Bellamy is a freelance writer and MPH candidate at the Colorado School of Public Health studying Global Community and Behavioral Health. 

 

 

Reviewed 1/22 by Andrea Nederveld, MD, MPH. Dr. Nederveld is a practicing Pediatrician and Internist, Assistant Professor at the University of Colorado Department of Family Medicine and Director of Partners Engaged in Achieving Change in Health (PEACHnet).

 

Note: The information provided on our site is for educational purposes only and does not constitute or substitute for professional medical advice. Please consult your healthcare provider before starting or stopping any treatment. We are not liable for risks or issues associated with using or acting on this information. If you or others need immediate attention please call the National Suicide Prevention Lifeline at 800-273-8255 or text the Crisis Text Line at 741741.