Suicidal Behavior Tied to Chronic Pain Is Different for Black Adults

According to the National Council on Aging, older adults make up only 12% of the US population, yet 18% of suicides,¹ with chronic pain being a known risk factor for suicide and suicidal behaviors.² Black older adults (65-plus) are disproportionately affected by the limitations of chronic pain,³ and in addition are more likely to be underdiagnosed, misdiagnosed, or unable to get adequate treatments, according to a 2003 National Academies of Medicine report.⁴

Methods

The cross-sectional study included 437 home-based participants in a large metropolitan area in the Southeast United States who received home-delivered meals. Participants were between 60 and 103 years old; 72.3% were female; 73.7% identified as Black, and 26.3% identified as white. Data were collected by in-person interviews.

Chronic pain was assessed using the PCP-S 17-item chronic pain profile across three sub-scales: pain severity, pain interference, and pain-related emotional burden. The Kessler Distress Scale (K-6) was used to assess psychological distress. Suicidal desire was assessed using the Interpersonal Needs Questionnaire (INQ) using two sub-scales, Perceived Burdensomeness and Thwarted Belonging. Participants ranked each item on the INQ along a seven-point scale, which ranged from “not true at all for me” to “very true for me.”

Examples of the statements included: “These days, the people in my life would be better off if I were gone,” and “These days, I often feel like an outsider in social gatherings.”

Findings

The data analysis revealed a complex relationship between race and the effects of pain. For Black participants as compared to whites, higher scores on the pain-related emotional burden sub-scale were associated with a greater elevation in perceived burdensomeness. This suggests that for Black older adults, the emotional toll of chronic pain is more likely than for white older adults to result in a sense that they are a burden to others and society. The data also showed a significant interaction effect of race and pain-related emotional burden on thwarted belongingness.

For Black participants, higher scores on the pain-related emotional burden sub-scale were more strongly associated with higher levels of thwarted belongingness. Also, for Black older adults, pain-related emotional burden had a significantly stronger association with suicide desire.

These findings, the researchers suggested, are best viewed through a cultural lens. For example, they cite research indicating that for Black older adults, the fear of becoming dependent on others is a significant part of pain. They also point to evidence that social engagement with family, friends, and support networks are core values for Black older adults and may serve as protection from suicidal behaviors. Chronic pain can make it difficult to take advantage of social resources, thus inhibiting the protective effect of these networks. “It is possible,” the authors wrote, “that the emotional toll of chronic pain increases the distance Black older adults have with family members and caregivers, thus negatively impacting the presence of close reciprocal friendships, and belongingness, and increasing loneliness.”⁵

The fact that pain severity did not predict suicide desire suggests that pain assessments may not be sufficient to identify which patients may be at greater risk of suicide. Instead, “Clinicians may consider focusing more on the impact of chronic pain in a person’s life, the meaning behind the pain, and particularly how the pain interferes with activities of daily living, especially for Black older adults,” the authors wrote.⁵

“To have to live with pain in a society and system that does not treat your pain as they would the pain of other races can be disheartening,” said Sarafina Kankam, MD, assistant professor of anesthesiology and pain medicine specialist at the University of Kansas Medical Center. “It becomes a cycle where patients have pain, don’t trust that they will get adequate treatment, and then feel helpless and feel like they don’t belong. Ultimately the emotional and physical distress can cause people to break and take matters into their own hands to try to stop their pain.”