Suicidality in Chronic Pain.

1. Suicidality Poster References
Chronic pain and suicide risk: A comprehensive review M. Racine Prog
Neuropsychopharmacol Biol Psychiatry 2018 Vol. 87 Issue Pt B Pages 269-280
Death by suicide is one of the leading causes of mortality worldwide. Because individuals
with chronic pain are at least twice as likely to report suicidal behaviors or to complete
suicide, it is of utmost importance to target which risk factors contribute the most to
increasing suicidality. This comprehensive review aims to provide an update on research
advancements relating to the identification of potential risk factors for suicidality in
individuals with chronic pain. Supporting the results of prior reviews, we found robust
evidence that chronic pain itself, regardless of type, was an important independent risk
factor for suicidality. The only sociodemographic factor found to be associated with
suicidality in individuals with chronic pain was being unemployed/disabled. Depressive
symptoms, anger problems, harmful habits (e.g. smoking, alcohol misuse, illicit drugs),
childhood or adulthood adversities, and family history of depression/suicide were all also
identified as general risk factors. Regarding pain-relatedfactors, sleep problems, poorer
perceived mental health, concurrent chronic pain conditions, and more frequent episodes of
intermittent pain, were all found to be predictors of suicidality. Unexpectedly, pain
characteristics (e.g. type, duration, and intensity/severity) and physical status (e.g. pain
interference or disability) were not related to suicide risk. We also identified promising new
psychosocial factors (e.g. mental defeat, pain catastrophizing, hopelessness, perceived
burdensomeness and thwarted belongingness) associated with suicidality outcomes. A large
number of these factors are amenable to change through targeted intervention, highlighting
the importance of comprehensively assessing chronic pain patients at risk for suicide, while
also incorporating a suicide prevention component into chronic pain management
programs.
Suicidality in chronic pain: a review of the prevalence, risk factors and psychological
link. N. K. Tang and C. Crane Psychol Med 2006 Vol. 36 Issue 5 Pages 575-86 Accession
Number: 16420727 DOI: 10.1017/s0033291705006859
BACKGROUND: This paper reviews and integrates the growing literature concerning the
prevalence of and risk factors for suicidality in chronic pain. METHOD: A series of systematic
searches in MEDLINE and PsychINFO identified 12 relevant articles examining suicide, suicide
attempts, and suicidal ideation in chronic pain. A selection of theoretical and empirical work
identifying psychological processes that have been implicated in both the pain and suicide
literature and which may be related to increased suicidality was also reviewed. RESULTS:
Relative to controls, risk of death by suicide appeared to be at least doubled in chronic pain
patients. The lifetime prevalence of suicide attempts was between 5% and 14% in individuals
with chronic pain, with the prevalence of suicidal ideation being approximately 20%. Eight
risk factors for suicidality in chronic pain were identified, including the type, intensity and

2. duration of pain and sleep-onset insomnia co-occurring with pain, which appeared to be
pain-specific. Helplessness and hopelessness about pain, the desire for escape from pain,
pain catastrophizing and avoidance, and problem-solving deficits were highlighted as
psychological processes relevant to the understanding of suicidality in chronic pain.
CONCLUSIONS: Programmatic research is urgently required to investigate the role of both
general and pain-specificrisk factors for suicidality, to examine how the psychological
processes mentioned above mediate or exacerbatesuicidality, and to develop enhanced
interventions for pain patients at risk.
Association of Dose Tapering With Overdose or Mental Health Crisis Among Patients
Prescribed Long-term Opioids
Agnoli, G. Xing, D. J. Tancredi, E. Magnan, A. Jerant and J. J. Fenton
Jama 2021 Vol. 326 Issue 5 Pages 411-419
Accession Number: 34342618 PMCID: PMC8335575 University of California Davis School of
Medicine Dean's Office (scholar in women's health research; BIRCWH/K12) during the
conduct of the study. No other disclosures were reported. DOI: 10.1001/jama.2021.11013
IMPORTANCE: Opioid-related mortality and national prescribing guidelines have led to
tapering of doses among patients prescribed long-term opioidtherapy for chronic pain.
There is limited information about risks related to tapering, including overdose and mental
health crisis. OBJECTIVE: To assess whether there are associations between opioid dose
tapering and rates of overdose and mental health crisis among patients prescribed stable,
long-term, higher-dose opioids. DESIGN, SETTING, AND PARTICIPANTS: Retrospective
cohort study using deidentifiedmedical and pharmacy claims and enrollment data from the
OptumLabs Data Warehouse from 2008 to 2019. Adults in the US prescribed stable higher
doses (mean ≥50 morphine milligramequivalents/d) of opioids for a 12-month baseline
period with at least 2 months of follow-up were eligiblefor inclusion. EXPOSURES: Opioid
tapering, defined as at least 15% relative reduction in mean daily dose during any of 6
overlapping 60-day windows within a 7-month follow-up period. Maximum monthly dose
reduction velocity was computed during the same period. MAIN OUTCOMES AND
MEASURES: Emergency or hospital encounters for (1) drug overdose or withdrawal and (2)
mental health crisis (depression, anxiety, suicide attempt) during up to 12 months of follow-
up. Discrete time negative binomial regression models estimatedadjusted incidence rate
ratios (aIRRs) of outcomes as a function of tapering (vs no tapering) and dose reduction
velocity. RESULTS: The final cohort included 113 618 patients after 203 920 stable baseline
periods. Among the patients who underwent dose tapering, 54.3% were women (vs 53.2%
among those who did not undergo dose tapering), the mean age was 57.7 years (vs 58.3
years), and 38.8% were commercially insured (vs 41.9%). Posttapering patient periods were
associated with an adjusted incidence rate of 9.3 overdose events per 100 person-years

3. compared with 5.5 events per 100 person-years in nontapered periods (adjusted incidence
rate difference, 3.8 per 100 person-years [95% CI, 3.0-4.6]; aIRR, 1.68 [95% CI, 1.53-1.85]).
Tapering was associated with an adjusted incidence rate of 7.6 mental health crisis events
per 100 person-years compared with 3.3 events per 100 person-years among nontapered
periods (adjusted incidence rate difference, 4.3 per 100 person-years [95% CI, 3.2-5.3]; aIRR,
2.28 [95% CI, 1.96-2.65]). Increasing maximum monthly dose reduction velocity by 10% was
associated with an aIRR of 1.09 for overdose (95% CI, 1.07-1.11) and of 1.18 for mental
health crisis (95% CI, 1.14-1.21). CONCLUSIONS AND RELEVANCE: Among patients
prescribed stable, long-term, higher-dose opioidtherapy, tapering events were significantly
associated with increased risk of overdose and mental health crisis. Although these findings
raise questions about potential harms of tapering, interpretation is limited by the
observational study design.
Outcomes in Long-term Opioid Tapering and Buprenorphine Transition: A
Retrospective Clinical Data Analysis
J. A. Sturgeon, M. D. Sullivan, S. Parker-Shames, D. Tauben and P. Coelho
Pain Med 2020 Vol. 21 Issue 12 Pages 3635-3644
Accession Number: 32163149 DOI: 10.1093/pm/pnaa029
BACKGROUND: There are significant medical risks of long-term opioid therapy (LTOT) for
chronic pain. Consequently, there is a need to identify effective interventions for the
reduction of high-dose full-agonist opioidmedication use. METHODS: The current study
details a retrospective review of 240 patients with chronic pain and LTOT presenting for
treatment at a specialty opioidrefill clinic. Patients first were initiated on an outpatient taper
or, if taper was not tolerated, transitioned to buprenorphine. This study analyzes potential
predictors of successful tapering, successful buprenorphine transition, or failure to complete
either intervention and the effects of this clinical approach on pain intensity scores. RESULTS:
One hundred seven patients (44.6%) successfully tapered their opioid medications under the
Centers for Disease Control and Prevention guideline target dose (90 mg morphine-
equianalgesic dosage), 45 patients (18.8%) were successfully transitioned to buprenorphine,
and 88 patients (36.6%) dropped out of treatment: 11 patients during taper, eight during
buprenorphine transition, and 69 before initiating either treatment. Conclusions. Higher
initial doses of opioids predicted a higher likelihoodof requiring buprenorphine transition,
and a co-occurring benzodiazepine or z-drug prescription predicted a greater likelihood of
dropout from both interventions. Patterns of change in pain intensity according to treatment
were mixed: among successfully tapered patients, 52.8% reported greater pain and 23.6%
reported reduced pain, whereas 41.8% reported increased pain intensity and 48.8% reported
decreased pain after buprenorphine transition. Further research is needed on predictors of

4. treatment retention and dropout, as well as factors that may mitigate elevatedpain scores
after reduction of opioid dosing.
Do users of regularly prescribed opioids have higher rates of substance use problems
than nonusers?
M. J. Edlund, M. Sullivan, D. Steffick, K. M. Harris and K. B. Wells
Pain Med 2007 Vol. 8 Issue 8 Pages 647-56
Accession Number: 18028043 DOI: 10.1111/j.1526-4637.2006.00200.x
OBJECTIVE: To determine whether individuals who use prescribed opioids for chronic
noncancer pain have higher rates of any opioid misuse, any problem opioid misuse,
nonopioid illicit drug use, nonopioid problem drug use, or any problem alcohol use,
compared with those who do not use prescribed opioids. METHODS: Respondents were
from a nationally representative survey (N = 9,279), which contained measures of regular use
of prescribed opioids, substance use problems, mental health disorders, physical health,
pain, and sociodemographics. RESULTS: In unadjusted models, compared with nonusers of
prescription opioids, users of prescription opioids had significantly higher rates of any opioid
misuse (odds ratio [OR] = 5.48, P < 0.001), problem opioid misuse (OR = 14.76, P < 0.001),
nonopioid illicit drug use (OR = 1.73, P < 0.01), nonopioid problemdrug use (OR = 4.48, P <
0.001), and problem alcohol use (OR = 1.89, P = 0.04). In adjusted models, users of
prescribed opioids had significantly higher rates of any opioid misuse (OR = 3.07, P < 0.001)
and problem opioid misuse (OR = 6.11, P < 0.001) but did not have significantly higher rates
of the other outcomes. CONCLUSIONS: Users of prescribed opioids had higher rates of
opioid and nonopioid abuse problems compared with nonusers of prescribed opioids, but
these higher rates appear to be partially mediated by depressive and anxiety disorders. It is
not possible to assign causal priority based on our cross-sectional data, but our findings are
more compatible with mental disorders leading to substance abuse among prescription
opioid users than prescription opioids themselves prompting substance abuse iatrogenically.
In patients receiving prescribed opioids, clinicians need to be alert to drug abuse problems
and potentially mediating mental health disorders.
Mental and Physical Health Conditions in US Combat Veterans: Results From the
National Health and Resilience in Veterans Study
M. M. Thomas, I. Harpaz-Rotem, J. Tsai, S. M. Southwick and R. H. Pietrzak
Prim Care Companion CNS Disord 2017 Vol. 19 Issue 3
Accession Number: 28657698 DOI: 10.4088/PCC.17m02118

5. OBJECTIVE: To identify sociodemographic and military characteristics of combat-exposed
and non-combat-exposed veterans in the United States and to compare rates of mental and
physical health conditions in these populations. METHODS: Data were analyzedfrom the
National Health and Resilience in Veterans Study (NHRVS), a contemporary, nationally
representative survey of 1,480 US veterans conducted September-October 2013.
Poststratification weights were appliedto analyses to permit generalizability of results to the
US veteran population. Outcomes measured included lifetime and current psychiatric
disorders and physical health conditions. RESULTS: A total 38% of US veterans reported
being exposed to combat. Compared to noncombat veterans, combat veterans were
younger, had greater household income, and served a greater number of years in the
military; were more likely to be male, to have served in the Marine Corps, and to use the
Veterans Affairs Healthcare System as their main source of health care; and reported a
greater number of lifetime potentially traumaticevents. After adjustment for these
sociodemographic and military differences, combat veterans were more than 3 times as
likely as noncombat veterans to screen positive for lifetimeposttraumatic stress disorder
(PTSD) and more than twice as likely for current PTSD and had 82% greater odds of
screening positive for current generalized anxiety disorder. After additionally controlling for
lifetime diagnoses of PTSD and depression, alcohol or drug use disorder, and nicotine
dependence, combat veterans had 68% greater odds of having attempted suicide and 85%
and 38% greater odds of being diagnosed with a stroke and chronic pain, respectively.
Younger combat veterans were more likely than older combat veterans to screen positive for
lifetime (30.6% vs 10.1%) and current PTSD (19.2% vs 4.9%) and suicidal ideation (18.6% vs
6.9%) and to have been diagnosed with migraine headaches (12.8% vs 2.1%), while older
combat veterans were more likely than younger combat veterans to report having been
diagnosed with heart disease (19.2% vs 2.6%) and heart attack (13.9% vs 2.5%).
CONCLUSIONS: Compared to noncombat veterans in the United States, combat veterans
have elevated rates of PTSD, suicide attempt, stroke, and chronic pain independent of other
sociodemographic, military, and mental health factors. Younger combat veterans have
elevated rates of PTSD, suicidal ideation, and migraine headaches, while older combat
veterans have elevated rates of heart disease and heart attack. These results characterize the
population-based burden of mental and physical health conditions in combat veterans. They
further underscore the importance of age- and condition-sensitive screening, monitoring,
and treatment efforts in this population.
Bipolar Disorder and Suicide: a Review
J. N. Miller and D. W. Black
Curr Psychiatry Rep 2020 Vol. 22 Issue 2 Pages 6
Accession Number: 31955273 DOI: 10.1007/s11920-020-1130-0

6. PURPOSE OF REVIEW: Bipolar disorder has the highest rate of suicide of all psychiatric
conditions and is approximately 20-30 times that of the general population. The purpose of
this review is to discuss findings relevant to bipolar disorder and suicide. RECENT FINDINGS:
Risk factors include male gender, living alone, divorced, no children, Caucasian, younger age
(< 35 years), elderly age (> 75 years), unemployment, and a personal history of suicide
attempt and family history of suicide attempt or suicide completion, as well as predominant
depressive polarity. Suicide is associated with the depressed or mixed subtypes, not mania.
Although there are emerging treatments for bipolar depression, such as ketamine and TMS,
lithium remains the only medication associatedwith lowered suiciderates in bipolar
disorder. Understanding clinical and demographic risk factors for suicide in bipolar disorder
remains the best way to prevent suicidal behavior. Early intervention and treatment with
anti-suicidal medications, such as lithium, along with close observation and follow-up is the
best way to mitigate suicide in patients with bipolar disorder.
Bipolar Disorder
F. Carvalho, J. Firth and E. Vieta
N Engl J Med 2020 Vol. 383 Issue 1 Pages 58-66
Accession Number: 32609982 DOI: 10.1056/NEJMra1906193
Comorbidity of fibromyalgia and psychiatric disorders
L. M. Arnold, J. I. Hudson, P. E. Keck, M. B. Auchenbach, K. N. Javaras and E. V. Hess
J Clin Psychiatry 2006 Vol. 67 Issue 8 Pages 1219-25
Accession Number: 16965199 DOI: 10.4088/jcp.v67n0807
OBJECTIVE: To assess the co-occurrence of fibromyalgia with psychiatric disorders in
participants of a fibromyalgia family study. METHOD: Patients (probands) with fibromyalgia,
control probands with rheumatoid arthritis, and first-degree relatives of both groups
completed a structured clinical interview and tender point examination. The co-occurrence
odds ratio (OR) (the odds of a lifetime comorbid DSM-IV disorder in an individual with
fibromyalgia divided by the odds of a lifetime comorbid disorder in an individual without
fibromyalgia, adjusted for age and sex) was calculated; observations were weightedby the
inverse probability of selection, based on the fibromyalgia status of the pro-band; and
standard errors were adjusted for the correlation of observations within families. The study
was conducted from September 1999 to April 2002. RESULTS: We evaluated 78 fibromyalgia

7. pro-bands and 146 of their relatives, and 40 rheumatoid arthritis probands and 72 of their
relatives. Among the relatives of both proband groups, we identified 30 cases of
fibromyalgia, bringing the total number of individuals with fibromyalgia to 108, compared
with 228 without fibromyalgia. The co-occurrence ORs for specific disorders in
individuals with versus those without fibromyalgia were as follows: bipolar disorder:
153 (95% CI = 26 to 902, p < .001); major depressive disorder: 2.7 (95% CI = 1.2 to 6.0,
p = .013); any anxiety disorder: 6.7 (95% CI = 2.3 to 20, p < .001); any eating disorder:
2.4 (95% CI = 0.36 to 17, p = .36); and any substance use disorder: 3.3 (95% CI = 1.1 to
10, p = .040). CONCLUSIONS: There is substantial lifetime psychiatric comorbidity in
individuals with fibromyalgia. These results have important clinical and theoretical
implications, including the possibility that fibromyalgia might share underlying
pathophysiologic links with some psychiatric disorders.
The Prevalence of Psychiatric and Chronic Pain Comorbidities in Fibromyalgia: an
ACTTION systematic review
B. A. Kleykamp, M. C. Ferguson, E. McNicol, I. Bixho, L. M. Arnold, R. R. Edwards, et al.
Semin Arthritis Rheum 2021 Vol. 51 Issue 1 Pages 166-174
Accession Number: 33383293 DOI: 10.1016/j.semarthrit.2020.10.006
Fibromyalgia (FM) is a chronic widespread pain condition that overlaps with multiple
comorbid health conditions and contributes to considerable patient distress. The aim of this
review was to provide a systematic overview of psychiatric and chronic pain comorbidities
among patients diagnosed with FM and to inform the development of recommendations for
the design of clinical trials. Thirty-one, cross-sectional, clinical epidemiology studies that
evaluated patients diagnosedwith FM were included for review. None of the reviewed
studies reported on the incidence of these comorbidities. Sample size-weighted prevalence
estimates were calculated when prevalence data were reported in 2 or more studies for the
same comorbid condition. The most prevalent comorbidity across all studies reviewedwas
depression/major depressive disorder (MDD) with over half of the patients included having
this diagnosis in their lifetime (weighted prevalenceup to 63%). In addition, nearly one-third
of FM patients examined had current or lifetime bipolar disorder, panic disorder, or post-
traumatic stress disorder. Less common psychiatric disorders reported includedgeneralized
anxiety disorder, obsessive compulsive disorder, and specificphobias (agoraphobia, social
phobia). There were fewer studies that examined chronic pain comorbidities among FM
patients, but when evaluated, prevalence was also high ranging from 39% to 76% (i.e.,
chronic tension-type or migraine headache, irritable bowel syndrome, myofascial pain
syndrome, and temporomandibular disorders). The results of the review suggest that
depression and chronic pain conditions involving head/jaw pain and IBS were elevated
among FM patients compared to other conditions in the clinic-based studies. In contrast,

8. anxiety-related disorders were much less common. Addressing the presence of these
comorbid health conditions in clinical trials of treatments for FM would increase the
generalizability and real-world applicability of FM research.
Fibromyalgia and bipolar disorder: extent of comorbidity and therapeutic implications
M. C. Di Tommaso Morrison, F. Carinci, G. Lessiani, E. Spinas, S. K. Kritas, G. Ronconi, et al.
J Biol Regul Homeost Agents 2017 Vol. 31 Issue 1 Pages 17-20
Accession Number: 28337866
Fibromyalgia (FM) is a syndrome that affects muscles and soft tissues. Presenting symptoms
include chronic muscle pain, fatigue, sleep problems and psychological symptoms, including
depression and anxiety. There exists strong evidence of a comorbidity between FM and
Bipolar Disorder (BD). In this study, papers from 2006 to February 2016 that examined the
comorbidity and etiological similarities of FM and BD were reviewed, as well as the
therapeutic implications of these findings. The reviewed articles showed that an adequate
psychiatric screening for BD is recommended in FM patients with depressive symptoms, in
order to decrease administration of antidepressants for BD, due to the lack of proven
efficacy, and to limit antidepressant-induced mania. Alternativetherapies, such as
agomelatine, memantine and psychotherapic treatment should be considered.
Prevalence of fibromyalgia and co-morbid bipolar disorder: A systematic review and
meta-analysis
P. A. Kudlow, J. D. Rosenblat, C. R. Weissman, D. S. Cha, R. Kakar, R. S. McIntyre, et al.
J Affect Disord 2015 Vol. 188 Pages 134-42
Accession Number: 26363263 DOI: 10.1016/j.jad.2015.08.030
BACKGROUND: Fibromyalgia (FM) is a chronic disorder with high morbidity and significant
health service utilization costs. Few studies have reported on the phenotypic overlap of FM
and bipolar disorder (BD). The aim of this review is to qualitatively and quantitatively
summarize the results and clinical implications of the extant literature on the co-occurrence
of FM and BD. METHODS: A systematic search of PubMed/Medline, Cochrane, PsycINFO,
CINAHL and Embase was conducted to search for relevant articles. Articles were included if
incidence and/or prevalence of BD was determinedin the FM sample. Results of prevalence
were pooled from all studies. Pooled odds ratio (OR) was calculated based on case-control
studies using standard meta-analyticmethods. RESULTS: A total of nine studies were

9. included. The pooled rate of BD comorbidity in samples of FM patients was 21% (n=678);
however, results varied greatly as a function of study methodology. Case-controlled studies
revealed a pooled OR of 7.55 of BD co-morbidity in samples of FM patients [95% Confidence
Interval (CI)=3.9-14.62, FM n=268, controls n=413] with low heterogeneity (I(2)=0%).
LIMITATIONS: The current study was limited by the low number of available studies and
heterogeneity of study methods and results. CONCLUSIONS: These data strongly suggest an
association between BD and FM. Future studies employing a validateddiagnostic screen are
needed in order to more accurately determine the prevalence of BD in FM. An adequate
psychiatric assessment is recommended in FM patients with suspected symptoms consistent
with BD prior to administration of antidepressants in the treatment of FM.
Opioid dose and risk of suicide
M. A. Ilgen, A. S. B. Bohnert, D. Ganoczy, M. J. Bair, J. F. McCarthy and F. C. Blow
Pain 2016 Vol. 157 Issue 5 Pages 1079-1084
Accession Number: 26761386 PMCID: PMC4939394 DOI: 10.1097/j.pain.0000000000000484
Chronic pain is associated with increased risk of suicide, and opioids are commonly used to
treat moderate to severe pain. However, the association between opioiddose and suicide
mortality has not been examined closely. This retrospective data analysis described the risk
of suicide associated with differing prescribed opioiddoses. Data were from Veterans Affairs
health care system treatment records and the National Death Index. Records analyzedwere
those of Veterans Affairs patients with chronic pain receiving opioids in fiscal years 2004 to
2005 (N = 123,946). Primary predictors were maximum prescribed morphine-equivalent daily
opioid dose and opioid fill type. The main outcome measured was suicide death, by any
mechanism, and intentional overdose death during 2004 to 2009. Controlling for
demographic and clinical characteristics, higher prescribed opioiddoses were associated
with elevated suicide risk. Compared with those receiving ≤20 milligrams/day (mg/d), hazard
ratios were 1.48 (95% confidence intervals [CI], 1.25-1.75) for 20 to <50 mg/d, 1.69 (95% CI,
1.33-2.14) for 50 to <100 mg/d, and 2.15 (95% CI, 1.64-2.81) for 100+ mg/d. The magnitude
of association between opioid dose and suicide by intentional overdose was not
substantially different from that observed for the overall measure of suicide mortality. Risk of
suicide mortality was greater among individuals receiving higher doses of opioids, and
treatment providers may want to view high opioid dose as a marker of elevated risk for
suicide. Additional research is needed on opioid use, pain treatment, and suicide.
Chronic multisite pain in major depression and bipolar disorder: cross-sectional study of
149,611 participants in UK Biobank
B. I. Nicholl, D. Mackay, B. Cullen, D. J. Martin, Z. Ul-Haq, F. S. Mair, et al.

10. BMC Psychiatry 2014 Vol. 14 Pages 350
Accession Number: 25490859 PMCID: PMC4297369 DOI: 10.1186/s12888-014-0350-4
BACKGROUND: Chronic pain has a strong association with major depressive disorder (MDD), but
there is a relative paucity of studies on the association between chronic multisite pain and
bipolar disorder (BD). Such studies are required to help elucidate the complex biological and
psychological overlap between pain and mood disorders. The aim of this study is to investigate
the relationship between chronic multisite pain and mood disorder across the unipolar-bipolar
spectrum. METHODS: We conducted a cross-sectional study of 149,611 UK Biobank participants.
Self-reported depressiveand bipolar features were used to categorise participants into MDD
and BD groups and a non-mood disordered comparison group. Multinomial logistic regression
was used to establish whether there was an association between extent of chronic pain
(independent variable) and mood disorder category (dependent variable), using no pain as the
referent category, and adjusting for a wide range of potential sociodemographic, lifestyle and
comorbidity confounders. RESULTS: Multisite pain was significantly more prevalent in
participants with BD and MDD, for example, 4-7 pain sites: BD 5.8%, MDD 4.5%, and comparison
group 1.8% (p < 0.001). A relationship was observed between extent of chronic pain and
risk of BD and persisted after adjusting for confounders (relative to individuals with no
chronic pain): 2-3 sites RRR of BD 1.84 (95% CI 1.61, 2.11); 4-7 sites RRRof BD 2.39 (95%
CI 1.88, 3.03) and widespread pain RRR of BD 2.37 (95% CI 1.73, 3.23). A similar relationship
was observed between chronic pain and MDD: 2-3 sites RRR of MDD 1.59 (95% CI 1.54, 1.65); 4-
7 sites RRR of MDD 2.13 (95% CI 1.98, 2.30); widespread pain RRR of MDD 1.86 (95% CI 1.66,
2.08). CONCLUSIONS: Individuals who report chronic pain and multiple sites of pain are more
likely to have MDD and are at higher risk of BD. These findings highlight an important aspect of
comorbidity in MDD and BD and may have implications for understanding the shared
neurobiology of chronic pain and mood disorders.
The prevalence of pain in bipolar disorder: a systematic review and large-scale meta-
analysis
B. Stubbs, L. Eggermont, A. J. Mitchell, M. De Hert, C. U. Correll, A. Soundy, et al.
Acta Psychiatr Scand 2015 Vol. 131 Issue 2 Pages 75-88
Accession Number: 25098864 DOI: 10.1111/acps.12325
OBJECTIVE: To conduct a meta-analysis investigating the prevalence of pain in people with
bipolar disorder (BD). METHOD: A systematic review and random effects meta-analysis

11. searching major electronic databases from inception till 01/2014 in accordance with the
PRISMA statement. We included articles reporting quantitative data on the prevalence of
pain in people with BD with or without a healthy control group. Two independent authors
conducted searches, extracted data, and completed methodological quality assessment.
RESULTS: Twenty two cross-sectional studies were included, representing 12,375,644
individuals (BD n=171,352, n controls=12,204,292). The prevalence of pain in people with BD
was 28.9% (95% CI=16.4-43.4%, BD n=171,352). The relative risk (RR) of pain in BD
compared to controls was 2.14 (95% CI=1.67-2.75%, n=12,342,577). The prevalence of
migraine was 14.2% (95% CI=10.6-18.3%, BD n=127,905), and the RR was 3.30 (95% CI=2.27-
4.80%, n=6,732,220).About 23.7% (95% CI=13.1-36.3%, n=106,214) of people with BD
experienced chronic pain. Age, percentage of males, methodological quality, and method of
BD classification did not explain the observed heterogeneity. CONCLUSION: People with BD
experience significantly increased levels of pain (particularly chronic pain and migraine). The
assessment and treatment of pain should form an integral part of the management of BD.
The Prevalence of Psychiatric and Chronic Pain Comorbidities in Fibromyalgia: an
ACTTION systematic review
B. A. Kleykamp, M. C. Ferguson, E. McNicol, I. Bixho, L. M. Arnold, R. R. Edwards, et al.
Semin Arthritis Rheum 2021 Vol. 51 Issue 1 Pages 166-174
Accession Number: 33383293 DOI: 10.1016/j.semarthrit.2020.10.006
Fibromyalgia (FM) is a chronic widespread pain condition that overlaps with multiple
comorbid health conditions and contributes to considerable patient distress. The aim of this
review was to provide a systematic overview of psychiatric and chronic pain comorbidities
among patients diagnosed with FM and to inform the development of recommendations for
the design of clinical trials. Thirty-one, cross-sectional, clinical epidemiology studies that
evaluated patients diagnosedwith FM were included for review. None of the reviewed
studies reported on the incidence of these comorbidities. Sample size-weighted prevalence
estimates were calculated when prevalence data were reported in 2 or more studies for the
same comorbid condition. The most prevalent comorbidity across all studies reviewedwas
depression/major depressive disorder (MDD) with over half of the patients included having
this diagnosis in their lifetime (weighted prevalenceup to 63%). In addition, nearly one-third
of FM patients examined had current or lifetime bipolar disorder, panic disorder, or post-
traumatic stress disorder. Less common psychiatric disorders reported includedgeneralized
anxiety disorder, obsessive compulsive disorder, and specificphobias (agoraphobia, social
phobia). There were fewer studies that examined chronic pain comorbidities among FM
patients, but when evaluated, prevalence was also high ranging from 39% to 76% (i.e.,
chronic tension-type or migraine headache, irritable bowel syndrome, myofascial pain
syndrome, and temporomandibular disorders). The results of the review suggest that

12. depression and chronic pain conditions involving head/jaw pain and IBS were elevated
among FM patients compared to other conditions in the clinic-based studies. In contrast,
anxiety-related disorders were much less common. Addressing the presence of these
comorbid health conditions in clinical trials of treatments for FM would increase the
generalizability and real-world applicability of FM research.
Chronic pain diagnoses and opioid dispensings among insured individuals with serious
mental illness
Owen-Smith, C. Stewart, M. M. Sesay, S. M. Strasser, B. J. Yarborough, B. Ahmedani, et al.
BMC Psychiatry 2020 Vol. 20 Issue 1 Pages 40
Accession Number: 32005200 PMCID: PMC6995196 DOI: 10.1186/s12888-020-2456-1
BACKGROUND: Individuals with major depressivedisorder (MDD) and bipolar disorder (BD)
have particularly high rates of chronic non-cancer pain (CNCP) and are also more likely to
receive prescription opioids for their pain. However, there have been no known studies
published to date that have examined opioidtreatment patterns among individuals with
schizophrenia. METHODS: Using electronic medical recorddata across 13 Mental Health
Research Network sites, individuals with diagnoses of MDD (N = 65,750), BD (N = 38,117) or
schizophrenia or schizoaffectivedisorder (N = 12,916) were identified and matched on age,
sex and Medicare status to controls with no documented mental illness. CNCP diagnoses
and prescription opioid medication dispensings were extractedfor the matched samples.
Multivariate analyses were conducted to evaluate (1) the odds of receiving a pain-related
diagnosis and (2) the odds of receiving opioids, by separate mental illness diagnosis
category compared with matched controls, controlling for age, sex, Medicare status,
race/ethnicity, income, medical comorbidities, healthcare utilization and chronic pain
diagnoses. RESULTS: Multivariablemodels indicatedthat having a MDD (OR = 1.90; 95%
CI = 1.85-1.95) or BD (OR = 1.71; 95% CI = 1.66-1.77) diagnosis was associated with increased
odds of a CNCP diagnosis after controlling for age, sex, race, income, medical comorbidities
and healthcare utilization. By contrast, having a schizophrenia diagnosis was associated with
decreased odds of receiving a chronic pain diagnosis (OR = 0.86; 95% CI = 0.82-0.90). Having
a MDD (OR = 2.59; 95% CI = 2.44-2.75) or BD (OR = 2.12; 95% CI = 1.97-2.28) diagnosis was
associated with increased odds of receiving chronic opioidmedications, even after
controlling for age, sex, race, income, medical comorbidities, healthcareutilization and
chronic pain diagnosis; having a schizophrenia diagnosis was not associated with receiving
chronic opioid medications. CONCLUSIONS: Individuals with serious mental illness, who are
most at risk for developing opioid-relatedproblems, continue to be prescribed opioids more
often than their peers without mental illness. Mental health clinicians may be particularly
well-suited to lead pain assessment and management efforts for these patients. Future

13. research is needed to evaluate the effectiveness of involving mental health clinicians in these
efforts.
Substance abuse in patients with bipolar disorder: A systematic review and meta-
analysis
T. Messer, G. Lammers, F. Müller-Siecheneder, R. F. Schmidt and S. Latifi
Psychiatry Res 2017 Vol. 253 Pages 338-350
Accession Number: 28419959 DOI: 10.1016/j.psychres.2017.02.067
By considering the debilitating outcome of co-occurring of bipolar disorder (BD) and
substance abuse, determination of risk factors of substance use disorders (SUD: abuse or
dependence of drugs and/or alcohol) is essential to identify the susceptible patients. The
purpose of this study was to clarify the major determinant factors of SUD among adults with
BD by reviewing the relevant literature. We systematically searched electronic databases
including PubMed (MEDLINE), EMBASE, OVID, Cochrane and Scopus for human studies
addressing the co-existence of bipolar disorder and SUD. All potential published papers up
to September 2016 have been reviewed. The statistical analysis was performed using
Comprehensive Meta-analysis version 2. Male gender (Odds ratio: 2.191 (95% CI: 1.121-
4.281), P 0.022), number of manic episodes (P: 0.001) and previous history of suicidality
(Odds ratio: 1.758 (95% CI: 1.156-2.674), P: 0.008) were associated to SUD in patients with
BD. SUD was not related to age, subtype of BD, hospitalization and co-existenceof anxiety
disorders or psychotic symptoms. SUD affects many aspects of BD regarding clinical course,
psychopathology and prognosis. Our study demonstrates that male gender, history of higher
number of manic episodes and suicidality are associated to higher susceptibility to SUD.
Thus, assignment of more intensive therapeutic interventions should be considered in
patients with increased risk of drug abuse to prevent development of SUD.