Suicidality in Primary Care Patients With Somatoform Disorders JAN F. WIBORG, PHD, DOROTHEE GIESELER, ALEXANDRA B. FABISCH, MD, KATHARINA VOIGT, DIPLPSYCH, ANNE LAUTENBACH, MD, ¨ WE, MD AND BERND LO Objective: To examine rates of suicidality in primary care patients with somatoform disorders and to identify factors that might help to understand and manage active suicidal ideation in these patients. Methods: We conducted a cross-sectional study screening 1645 primary care patients. In total, 142 patients fulfilled the criteria for a somatoform disorder. Suicidality and illness perceptions were assessed in these patients. Results: Of the 142 patients, 23.9% had active suicidal ideation during the previous 6 months; 17.6% had attempted to commit suicide in the past, the majority after onset of the somatoform symptoms. We tested two models with suicidal ideation as a dependent variable. In the first model, comorbid symptoms of depression (odds ratio [OR] = 1.17, 95% confidence interval [CI] = 1.03Y1.33) and previous suicide attempts (OR= 3.02, 95% CI = 1.06Y8.62) were significantly associated with suicidal ideation. Comorbid symptoms of anxiety did not yield significance. Illness perceptions and age of onset of the symptoms were then added to this model to test the role of somatoform-specific factors in addition to previous factors. In the complete model, comorbid symptoms of depression (OR = 1.15, 95% CI = 1.00Y1.32) and dysfunctional illness perceptions (OR = 1.06, 95% CI = 1.01Y1.11) were independently associated with active suicidal ideation, whereas the other factors did not yield significance. Conclusions: According to our data, suicidality seems to be a substantial problem in primary care patients with somatoform disorders. Dysfunctional illness perceptions may play a vital role in the understanding and management of active suicidal ideation in these patients, in addition to more established factors. Key words: somatoform disorders, primary care, suicidality, comorbidity, illness perceptions.
PHQ = Patient Health Questionnaire; GAD = Generalized Anxiety Disorder; GPs = general practitioners; CIDI = Composite International Diagnostic Interview; BIPQ = Brief Illness Perception Questionnaire; CI = confidence interval; SPSS = Statistical Package for the Social Sciences.
INTRODUCTION umerous studies have documented the risk for suicidality in patients with poor mental and physical health (1Y7). Most of these studies have concentrated on high-risk populations for suicidal acts with fatal consequences, such as patients with major depression. Suicidality in patients with somatoform disorders is poorly understood because of a lack of empirical studies. These patients usually experience physical complaints that cannot be explained by a medical condition but tend to dominate their life (8,9). The prevalence of somatoform disorders in medical care settings is generally high. In primary care, for example, the estimated prevalence ranges between 16% and 30% (10Y12). Comorbid depression and anxiety are common (10,12Y14). Recently, two studies investigated suicidality in patients with somatoform symptoms. De Klerk et al. (15) examined the routine outcome data of psychiatric outpatients and found that 45% of those patients who were labeled as somatoform reported about lifetime suicidal ideation or self-harm behavior. No attempt was made to correct this finding for comorbidity. Park et al. (16) studied suicidality in a community sample and found that people with unexplained pain had higher rates of suicidality than did people without such symptoms. Their findings were only partially explained by psychiatric comorbidity, so that the authors
N
From the Expert Centre for Chronic Fatigue (J.F.W.), Radboud University Nijmegen Medical Centre, the Netherlands; and the Department of Psychosomatic Medicine and Psychotherapy, University Medical Center HamburgEppendorf & Scho¨n Clinics, Hamburg-Eilbek, Germany. Address correspondence and reprint requests to Jan F. Wiborg, PhD, University Medical Center Hamburg-Eppendorf, MartinistraQe 52, 20246 Hamburg, Germany. E-mail: [email protected] Received for publication February 27, 2013; revision received September 7, 2013. DOI: 10.1097/PSY.0000000000000013 800
concluded that somatoform symptoms and psychiatric comorbidity may have acted together to produce suicidality in patients with unexplained pain. The idea that somatoform symptoms might play a role in the development and perpetuation of suicidality is in line with the cognitive model of suicidality introduced by Wenzel and Beck (17). According to their model, dysfunctional cognitive processes that are associated with the specific symptoms of patients can activate suicidal ideation, depending on the general level of stress and dispositional vulnerability of patients. These processes include biases in what patients believe about themselves and others as well as how they process new information. Wenzel and Beck (17) refer to the term cognitive content specificity in this context to make clear that the content of these cognitive processes varies depending on the specific symptoms of patients. Knowledge about the symptom-specific cognitive processes might thus help to trace pathways for the development of suicidality in patients with somatoform disorders, with vital implications for the prevention and management of suicidality in these patients. In patients with somatoform disorders, these cognitive biases may largely consist of dysfunctional illness perceptions that play a central role in cognitive behavioral models of medically unexplained symptoms. These models state that patients develop a belief that their physical symptoms are chronic and uncontrollable because physicians fail to find a pathophysiological cause for their suffering (18). Consistently, these patients tend to perceive many negative consequences in association with their unexplained symptoms including negative emotional responses such as depression and anxiety. Biases in the processing of new information are also of relevance, for example, in the context of attentional focusing of patients on their physical symptoms (19). Following the model of Wenzel and Beck (17), more extreme levels of these dysfunctional illness perceptions might facilitate suicidality in patients with somatoform disorders. The goals of the present study were a) to examine the rate of suicidality in primary care patients with somatoform disorders and (b) to identify factors that might help to understand and manage suicidal ideation in these patients. Based on the cognitive Psychosomatic Medicine 75:800Y806 (2013)
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SUICIDALITY AND SOMATOFORM DISORDERS METHODS Design and Sample
Figure 1. Flowchart of the study design including numbers of patients.
models of suicidality (17) and medically unexplained symptoms (18,19), we hypothesized that there is a significant relationship between the intensity and duration of dysfunctional illness perceptions on the one hand and the occurrence of active suicidal ideation on the other hand. Following these models, we expected that dysfunctional illness perceptions would contribute to the understanding of suicidal ideation in patients with somatoform disorders, independent of relevant psychiatric comorbidity and previous suicidal behavior.
We conducted a cross-sectional study with 41 general practitioners (GPs) at 19 locations. These GPs participated in a large regional research project (20) designed to improve the health care situation of patients with mental disorders in the Hamburg metropolitan area (Northern Germany). All GPs were visited on 2 to 4 days, depending on the size of the general practice. On these days, patients were asked in a consecutive order to answer a short questionnaire about their health status. All patients provided oral informed consent for an anonymous screening. Patients who were interviewed by telephone also provided written informed consent. The protocol for the study was approved by the ethics ¨ rztekammer Hamburg). Patients who committee of the local medical council (A were not able to fill in the screening questionnaire or to participate in a telephone interview because of physical or psychiatric impairment, patients with substantial language problems, and patients who were younger than 18 years were excluded. Data were collected between September 2011 and February 2012. A detailed chart of the patient flow is depicted in Figure 1. Of the 1882 primary care patients who were eligible for an anonymous screening of their symptoms in the context of our study, 1645 (87%) agreed to participate. Patients with severe somatic complaints (Patient Health Questionnaire [PHQ]-15) and patients with moderate somatic complaints in combination with at least moderate symptoms of depression (PHQ-9) and/or anxiety (Generalized Anxiety Disorder [GAD]-7) were asked to participate in a subsequent telephone interview to validate the somatoform character of the symptoms and to explore suicidality and illness perceptions. These patients were chosen in the context of the original research project because they were considered to be in need for adequate management of their symptoms (20). GPs completed a checklist for these patients in which somatic comorbidity and psychotropic drug intake (including pain medication) was documented. It was also assessed whether GPs had recommended specialized help by a mental health care professional to their patients. Of all patients who were asked for the telephone interview (n = 267), 156 (58%) ultimately participated. The mean (standard deviation) time between screening and telephone interview was 4.7 (2.4) weeks. Nonresponse analyses revealed that there were no significant differences in age, sex, and screening results between those patients who participated in our telephone interview and those who did not participate (data not shown). A total of 142 patients fulfilled the lifetime criteria for somatoform disorders according to the somatoform section of the Composite International Diagnostic Interview (CIDI), which implied that patients were experiencing a somatoform disorder at least once in their life. Twenty-four of these patients reported in this interview that the last episode of their somatoform symptoms occurred longer than 6 months before the current assessment. Based on the positive PHQ-15 screening results of these patients, which reflect clinically relevant symptoms during the previous 2 weeks, we considered the symptoms of these patients to be current as well and included these patients in our study. Most of the patients with a somatoform disorder were experiencing a somatoform pain disorder (n = 97) or an undifferentiated somatoform disorder (n = 43). Two patients had a somatization disorder. These 142 patients were included in the examination of suicidality rates in primary care patients with somatoform disorders (i.e., the first goal of our study). Because of missing data, we excluded six patients from the analyses that were conducted to identify factors that might help to understand and manage active suicidal ideation in these patients (i.e., the second goal of our study).
TABLE 1. Assessment of Suicidality During the Telephone Interview Type Ideation
Attempt
Content
Response
Have you thought about ending your life during the past 6 mo?
Yes/No
If yes, did you or have you made any specific plans to commit suicide?
Yes/No
If yes, did you or have you made any preparations to commit suicide?
Yes/No
Have you ever actively tried to end your life?
Yes/No
If yes, when did this attempt take place (first if more than one)?
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date
801
J. F. WIBORG et al. Instruments The PHQ was used to screen somatic complaints (PHQ-15) as well as comorbid symptoms of depression (PHQ-9) and anxiety (GAD-7) in general practice (21,22). On all subscales of the PHQ, a cutoff score of 10 (or higher) was used to indicate moderate symptoms and a cutoff score of 15 (or higher) was used to indicate severe symptoms. The latter cutoff has good sensitivity, while maximizing specificity for the identification of comorbid disorders of depression and anxiety (23). The PHQ-9 includes a suicidality item that asks for thoughts about being better off dead or hurting oneself. We used the PHQ-8 depression scale in subsequent analyses, which omits this suicidality item. Items that were left unanswered were interpreted as not relevant for the patient (i.e., calculated as zero in the sum scores). Cronbach > reliability coefficients have been shown to be .89 to .92 for the GAD-7, .79 to .80 for the PHQ-15, and .86 to .89 for the PHQ-9 with similar operating characteristics for the PHQ-8 (21Y23). In our study population, we found reliability coefficients of > = .90, .77, and .88 for the GAD-7, PHQ-15, and PHQ-9, respectively, with identical coefficients for the PHQ-9 and the PHQ-8 (i.e., .88). The somatoform section of the computerized lifetime version of the CIDI was used to validate our screening results and diagnose a somatoform disorder (24). In this section, patients first rate the severity of their physical symptoms and are then asked whether their symptoms were attributed to a physical condition, medication, or the use of drugs or alcohol by a medical professional. Patients with somatic comorbidity can qualify for a somatoform diagnosis in this section as long as their comorbidity is not the exclusive explanation for their complaints. Preoccupation with illness is also assessed. Interrater reliability of all CIDI sections has been shown to be good, with k values of 0.81 or higher (24). The computerized and telephone-administered CDI interviews were conducted by specifically trained medical students in the context of their doctoral dissertation. The assessment of suicidality was based on recommendations by Po¨ldinger (25) and included a set of standardized questions that were assessed by telephone (Table 1). All patients who answered the first question about suicidality with yes (i.e., those who thought about ending their life during the previous 6 months) were defined as suicidal ideators in subsequent analyses. Patients with acute suicidality were presented to a trained clinician by the interviewers after the telephone interview had been finished. The clinician decided about further actions. The Brief Illness Perception Questionnaire (BIPQ) was used to assess dysfunctional illness perceptions during the telephone interview (26). This version is based on the work of Weinman et al. (27) and Moss-Morris et al. (28). In the BIPQ, eight ordinal scales (0Y10) are used to asses eight different illness perceptions, including consequences, timeline, personal control, treatment control, identity, concern, understanding, and emotional response. The BIPQ has been shown to have adequate test-retest reliability with correlation coefficients between .48 and .70 at a 3-week reassessment of the single items (26). An overall sum score from all eight items was computed to represent the degree to which the complaints are perceived as problematic (higher scores represent more negative illness
perceptions) (29). Items 3, 4, and 7 were reverted for this purpose. We found a Cronbach > reliability coefficient of .68 for the sum score of the BIPQ in our sample.
Statistical Analysis Ninety-five percent confidence intervals for single proportions were calculated using the Wilson Score Method (30). Univariate differences between patients with and patients without suicidal ideation were tested using the MannWhitney U and Fisher exact tests. Next, we tested two consecutive models using multiple logistic regression analysis with active suicidal ideation as a dependent variable. In the baseline model, we included psychiatric comorbidity (i.e., comorbid symptoms of depression and anxiety) and previous suicide attempts as independent variables. In the second step, we added the sum score of dysfunctional illness beliefs (BIPQ) as an indicator of the intensity of the symptomspecific dysfunctional beliefs and the age of onset of the somatoform disorder as an indicator of the duration of the beliefs. We expected that the somatoformspecific factors would yield significance when they are controlled for the factors of the baseline model. In addition, we assumed that the total explained variance (Nagelkerke R2) of the first model would increase by entering the somatoformspecific factors. All tests were two sided, and the threshold for statistical significance was set at p e .05.We used SPSS (version 20) for our computations.
RESULTS We included 142 primary care patients with somatoform disorders (Fig. 1). The median age of these patients was 45.5 (18Y84) years, and 82% were female. GPs indicated that 23 (16%) of the 142 included patients were already receiving additional treatment by a mental health care professional and that they had recommended referral to such a professional in 39% (n = 46/119) of the remaining patients (no answer was interpreted as no treatment or referral). According to the GPs, 21% of the 142 patients were taking antidepressant medication; 13%, pain medication; 4%, benzodiazepines; and 2%, antipsychotic medication. At the time of the screening, 53 (37%) of the 142 included patients were bothered by thoughts of being better off dead or hurting oneself, according to the PHQ-9 suicidality item. The proportion of patients with a negative screening result who endorsed the suicidality item of the PHQ-9 was 90 (7%) of 1378 patients. The difference in proportion between the two groups was statistically significant ( p G .001), according to the Fisher exact test. Thirty-six (37%) of 97 patients with a somatoform pain disorder and 17 (40%) of 43 patients with an
TABLE 2. Suicidality Rates in Patients With Somatoform Disorders (n = 142) n
%
95% CI
53
37.3
29.8Y45.5 17.7Y31.6
Screening Thoughts of being better off dead or hurting oneself (PHQ-9) Interview Active suicidal ideation (past 6 mo)a
34
23.9
Concrete plans for suicidal act
10
7.0
3.9Y12.5
Preparations for suicidal act Previous suicide attempt (lifetime)b
2 25
1.4 17.6
0.4Y5.0 12.2Y24.7
Any suicidality reported during interviewa,b
46
32.4
25.2Y40.5
PHQ = Patient Health Questionnaire; CI = confidence interval. a Two patients declined to answer any questions about suicidality. b Two additional patients declined to answer questions about suicide attempts. 802
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SUICIDALITY AND SOMATOFORM DISORDERS TABLE 3. Univariate Testing of Differences Between Patients With and Without Suicidal Ideation Totala (n = 136)
No Suicidal Ideation (n = 106)
Suicidal Ideation (n = 30)
p
Ageb
45.5 (18Y84)
45.0 (18Y84)
46.0 (18Y82)
.92
Women
112 (82%)
85 (80%)
27 (90%)
.28
Married
46 (34%)
36 (34%)
10 (33%)
.99
76 (56%)
62 (59%)
14 (47%)
.30
10 (7%)
10 (9%)
0 (0%)
.12
1 (1%)
1 (1%)
0 (0%)
.99
Demographic
Employed Somatic comorbidity Coronary heart disease Multiple sclerosis Diabetes
14 (10%)
11 (10%)
3 (10%)
.99
COPD
9 (7%)
7 (7%)
2 (7%)
.99
Cancer
6 (4%)
4 (4%)
2 (7%)
.61
Arthritis
1 (1%)
1 (1%)
0 (0%)
.99
Psychiatric comorbidity Depression according to PHQ-8 None or mild (G10)
37 (27%)
33 (31%)
4 (13%)
.06
Moderate (Q10 and G15)
57 (42%)
49 (46%)
8 (27%)
.06
Severe (Q15)
42 (31%)
24 (23%)
18 (60%)
G.001
Anxiety according to GAD-7 None or mild (G10)
42 (31%)
35 (33%)
7 (23%)
.38
Moderate (Q10 and G15)
55 (40%)
48 (45%)
7 (23%)
.036
39 (29%) 25 (18%)
23 (22%) 12 (11%)
16 (53%) 13 (43%)
.001 G.001
15.0 (2Y66)
15.0 (2Y66)
14.0 (3Y43)
.032
5.0 (0Y10)
5.0 (0Y10)
7.0 (2Y10)
G.001
Severe (Q15) Previous suicide attempt Somatoform specificb Age onset symptoms BIPQ-consequences BIPQ-timeline
7.0 (0Y10)
6.0 (0Y10)
9.0 (0Y10)
.034
BIPQ-personal control
5.0 (0Y10)
5.5 (0Y10)
5.0 (0Y10)
.013
BIPQ-treatment control
7.0 (0Y10)
6.0 (0Y10)
7.0 (0Y10)
.51
BIPQ-identity BIPQ-concern
7.0 (0Y10) 5.0 (0Y10)
6.0 (0Y10) 5.0 (0Y10)
7.5 (4Y10) 6.5 (0Y10)
.005 .044
BIPQ-understanding
8.0 (0Y10)
8.0 (0Y10)
8.0 (0Y10)
.79
BIPQ-emotional response
7.0 (0Y10)
7.0 (0Y10)
9.0 (3Y10)
.001
COPD = chronic obstructive pulmonary disease; PHQ = Patient Health Questionnaire; GAD = Generalized Anxiety Disorder; BIPQ = Brief Illness Perception Questionnaire. Differences were tested with Mann-Whitney or Fisher exact test. a Six patients were excluded because of missing data. b Median scores (range).
undifferentiated somatoform disorder endorsed the suicidality item of the PHQ. In total, 46 patients reported about any suicidality during the telephone interview (Table 2). Two patients declined to answer any questions about suicidality, and two additional patients declined to answer questions about suicide attempts. All suicidality rates were based on the total sample of 142 included patients (missing values were interpreted as no suicidality). Most of the patients with suicidality had experienced active suicidal ideation during the previous 6 months. Of the 34 patients who answered positively to the active suicidal ideation item during the telephone interview, 29 (85%) patients had also endorsed the suicidality item of the PHQ-9 during the screening. Twenty-seven (28%) of 97 patients with a somatoform pain
disorder and 7 (16%) of 43 patients with an undifferentiated somatoform disorder reported about active suicidal ideation during the interview. Ten (7%) patients had concrete plans for a suicidal act during the same period. Twenty-five (18%) patients had previously engaged in a suicidal act. Most of these patients (n = 20/25) tried to commit suicide after onset of the somatoform symptoms. Univariate testing of differences between patients with and patients without suicidal ideation is presented in Table 3. Six patients were excluded from these and subsequent analyses because of missing data with respect to suicidality (n = 4) or illness perceptions (n = 2). According to our analyses, both groups did not differ significantly on demographic variables and somatic comorbidity. However, patients with suicidal ideation reported
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J. F. WIBORG et al. TABLE 4. Multiple Logistic Regression Analysis With Suicidal Ideation as a Dependent Variable (n = 136) Model 1, OR (95% CI) Previous suicide attempt
(1 = yes)
Level of comorbid depression (PHQ-8; range = 2Y24) Level of comorbid anxiety (GAD-7; range = 0Y21) Age onset somatoform symptoms (range = 2Y66 y) Dysfunctional illness perceptions (BIPQ sum; range = 1Y78)
3.02* (1.06Y8.62)
Model 2, OR (95% CI) 2.65 (0.90Y7.87)
1.17* (1.03Y1.33)
1.15* (1.00Y1.32)
1.02 (0.90Y1.16)
1.01 (0.88Y1.15) 0.98 (0.94Y1.02) 1.06* (1.01Y1.11)
PHQ = Patient Health Questionnaire; GAD = Generalized Anxiety Disorder; BIPQ = Brief Illness Perception Questionnaire; OR = odds ratio; CI = confidence interval. Six patients were excluded because of missing data. * p e .05.
significantly more severe comorbid depression and anxiety and were significantly more likely to have a history of suicide attempts compared with patients who did not have suicidal ideation. Patients with suicidal ideation also had a significantly earlier onset of somatoform symptoms and had significantly more dysfunctional illness perceptions. In particular, these perceptions included the idea that the physical symptoms had a profound negative effect on their life and would last a long time, with little chance to control them, while experiencing more negative emotions in reaction to these symptoms. Multiple logistic regression analysis was then conducted to test two different models with active suicidal ideation as a dependent variable (Table 4). In our baseline model, comorbid symptoms of depression and previous suicide attempts were significantly associated with suicidal ideation. Comorbid symptoms of anxiety did not yield significance in this model. In an additional step, we added age of onset of the somatoform symptoms and the overall sum score of the BIPQ to the baseline model. Comorbid depression and dysfunctional illness perceptions were both significantly associated with suicidal ideation in our complete model. Comorbid symptoms of anxiety, previous suicide attempts, and age of onset of the somatoform symptoms did not reach significance in this model. The additional step and both models were significant ( p G .05). Nagelkerke R2 increased from 0.272 in the first to 0.332 in the second model. DISCUSSION The present study is the first one, to our knowledge, that has examined suicidality in primary care patients with somatoform disorders. According to our data, suicidality seems to be a substantial problem in these patients. In the general medical population, the rate for suicidal ideation ranges between 1% and 10%, depending on how it is assessed, but can exceed 30% in patients with major depression (31,32). Rates of passive death wishes are usually higher than rates of active suicidal ideation. In line with previous studies, we found that the rate of suicidal ideation assessed with the PHQ (37%), which included passive death wishes, was higher than the rate of active suicidal ideation (24%), which was assessed during the telephone interview. In our sample of patients with 804
a negative screening result, the PHQ rate of suicidality was significantly lower (i.e., 7%). Ten of the 142 patients with a somatoform disorder actually had concrete plans for committing suicide. In total, our suicidality rate was lower than that of psychiatric outpatients with somatoform disorders reported by De Klerk et al. (15). They found a total rate of 45% but included lifetime suicidal ideation and self-harm behavior without suicidal intent. Many of our patients with active suicidal ideation reported about severe depression or anxiety as indicated by PHQ-8 and GAD-7 scores of 15 or higher. Patients with such high scores are most likely experiencing a comorbid depression or anxiety disorder (23), which suggests that psychiatric comorbidity is a prominent feature of somatoform patients with suicidal ideation. This finding is in line with a previous study about suicidality in patients with unexplained pain (16). The significant factor of our regression models with respect to psychiatric comorbidity was the level of depressive symptoms. In addition, we found that the level of dysfunctional illness perceptions was significantly related to active suicidal ideation independent of psychiatric comorbidity and previous suicidal behavior. This finding may suggest that knowledge about cognitions that are specific to the symptoms of patients may, in fact, help to trace individual pathways of suicidality, as suggested by the cognitive model of suicidality (17). Our findings do not support the idea that suicidal ideation in patients with somatoform disorders is merely a consequence of psychiatric comorbidity and has nothing to do with the symptom-specific cognitive processes of these patients. Generally, our cross-sectional exploration of potential factors of suicidal ideation should be understood as preliminary. Future studies need to replicate and extend our findings. Such studies should focus on longitudinal data collection to enhance the understanding of the course of suicidality in patients with somatoform disorders and thereby help to elucidate whether an increase in intensity in somatoform-specific cognitive processes actually precedes the occurrence of suicidal ideation in these patients. At the same time, other potentially influential variables should be included in these studies. One of the priorities would be to better understand the role that general levels of stress and dispositional vulnerabilities play in the development of suicidal ideation in patients with somatoform disorders. Psychosomatic Medicine 75:800Y806 (2013)
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SUICIDALITY AND SOMATOFORM DISORDERS Following the model of Wenzel and Beck (17), hopelessness could be tested as a potential mediator of the relationship between somatoform-specific dysfunctional cognitive processes and suicidal ideation. Patients with somatoform disorders might thus come to the conclusion that their situation is hopeless and engage in suicidal ideation because they have developed extremely dysfunctional beliefs about their unexplained physical symptoms. If this assumption holds true, it may convey an important lesson for the prevention and treatment of suicidality that is not self-evident when clinicians are solely referred to the psychiatric comorbidity of these patients. This lesson encompasses the relative importance of somatoform-specific cognitive contents in the management of suicidality in patients with somatoform disorders in contrast to other patient populations such as patients with major depression without a history of somatoform disorders. Specific interventions for dysfunctional illness perceptions (33,34) could be further elaborated and tested in this context. Apart from the cross-sectional design of our study, there are also other potential limitations. We had to exclude patients with moderate somatic complaints who had no or only mild levels of comorbid depression and anxiety because of the design of the original research project from which our data were derived (20). This research project focused on primary care patients who were most likely in need for help by a mental health care professional. If psychiatric comorbidity is, in fact, a prominent feature of suicidal patients with somatoform disorders, rates of suicidality might be lower in the group of excluded patients who do not have clinically relevant levels of depression and anxiety. Patient attrition may also have biased the findings of this study. In particular, substantial loss of participants appeared among patients with a positive screening result. Nonresponse analysis suggested, however, that such a bias is no likely explanation for our findings. The total rate of positive screening results of 16% (n = 267/1645) as an indicator for the frequency of somatoform disorders in our study population is thereby in line with a Dutch study about the prevalence of somatoform disorders in primary care (10). Although we were not able to validate the somatoform character of the physical symptoms in all of the 267 patients because of attrition, most of the positively screened patients who participated in our telephone interview also fulfilled lifetime criteria for a somatoform disorder (i.e., 990%). In general, the cutoff score on the PHQ-15 used in this study has been shown to be a good indicator for detecting somatoform disorders in primary care patients (35). We included all patients with a lifetime history of a somatoform disorder based on their PHQ-15 screening results. This strategy may have inflated the rate of current somatoform disorders in our study. This effect might have been further increased by the fact that we did not include the complete CIDI interview but focused on its somatoform section instead. However, other studies suggest that our total rate of 16% is within the lower rather than the higher area of estimated prevalence rates for current somatoform disorders in primary care settings (10Y12). Potential overdiagnosing of somatoform disorders is also a general problem of structured diagnostic interviews such as the CIDI (24). A
modified classification of these disorders in the upcoming Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, may help to increase reliability (36). Using the sum score of the BIPQ rather than its individual items might not have been the ideal strategy to determine the relative importance of each of these dimensions in understanding suicidal ideation in patients with somatoform disorders. However, we think that there are several advantages associated with this strategy in the context of our study. The sum score might generally better reflect the overall intensity of dysfunctional cognitive processes, as described by Wenzel and Beck (17). In addition, the sum score is easier to handle statistically because it can also be tested in samples with restricted size while avoiding the problem of multicollinearity among single items. That we conducted the BIPQ by telephone might have biased the response of our patients in comparison with the selfadministered variant of the questionnaire. It seems unlikely, however, that variables such as social desirability play a vital role in the administration of the BIPQ. Unfortunately, we were not able to collect data about the recognition of suicidality by GPs in our sample. Our finding that only about half of the patients either were in treatment by a mental health professional or had received a recommendation for referral to such treatment seems in line with previous research showing that many GPs are ambivalent about medically unexplained symptoms and the potential of mental health care providers to treat patients with these symptoms effectively (37). At the same time, the rate for treatment by a mental health care professional or recommendation for referral to such a professional was considerably higher in patients who engaged in active suicidal ideation (i.e., 77% as opposed to 49%). This finding may suggest that GPs are generally sensitive to the severity of individual cases. Based on our findings, GPs may want to use patients’ routine reports about how they perceive their physical complaints as an additional cue for identifying active suicidal ideation in patients with somatoform disorders. In particular, those patients may engage in suicidal ideation who report about a severe impact of the physical symptoms on their life including intense negative emotional responses, little perceived control, and the expectation that the symptoms will last a long time. Based on these and upcoming insights, specific interventions for the management of suicidality in patients with somatoform disorders could be developed and tested as part of evidence-based practice for these patients. We thank Dr. Alexandra Murray for her critical review of the manuscript. Source of Funding and Conflicts of Interest: The study from which the data for this article were derived was funded by the German Federal Ministry of Education and Research (principal investigator: B.L.). The funding source had no formal role in the interpretation of the data or preparation of the manuscript. All authors declare the following: no support from any organization (other than mentioned as funding) for the submitted work, no financial relationships with any organizations that might have an interest in the submitted work in the previous 3 years, and no other relationships or activities that could seem to have influenced the submitted work.
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Psychosomatic Medicine 75:800Y806 (2013)
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PHQ = Patient Health Questionnaire; GAD = Generalized Anxiety Disorder; GPs = general practitioners; CIDI = Composite International Diagnostic Interview; BIPQ = Brief Illness Perception Questionnaire; CI = confidence interval; SPSS = Statistical Package for the Social Sciences.
INTRODUCTION umerous studies have documented the risk for suicidality in patients with poor mental and physical health (1Y7). Most of these studies have concentrated on high-risk populations for suicidal acts with fatal consequences, such as patients with major depression. Suicidality in patients with somatoform disorders is poorly understood because of a lack of empirical studies. These patients usually experience physical complaints that cannot be explained by a medical condition but tend to dominate their life (8,9). The prevalence of somatoform disorders in medical care settings is generally high. In primary care, for example, the estimated prevalence ranges between 16% and 30% (10Y12). Comorbid depression and anxiety are common (10,12Y14). Recently, two studies investigated suicidality in patients with somatoform symptoms. De Klerk et al. (15) examined the routine outcome data of psychiatric outpatients and found that 45% of those patients who were labeled as somatoform reported about lifetime suicidal ideation or self-harm behavior. No attempt was made to correct this finding for comorbidity. Park et al. (16) studied suicidality in a community sample and found that people with unexplained pain had higher rates of suicidality than did people without such symptoms. Their findings were only partially explained by psychiatric comorbidity, so that the authors
N
From the Expert Centre for Chronic Fatigue (J.F.W.), Radboud University Nijmegen Medical Centre, the Netherlands; and the Department of Psychosomatic Medicine and Psychotherapy, University Medical Center HamburgEppendorf & Scho¨n Clinics, Hamburg-Eilbek, Germany. Address correspondence and reprint requests to Jan F. Wiborg, PhD, University Medical Center Hamburg-Eppendorf, MartinistraQe 52, 20246 Hamburg, Germany. E-mail: [email protected] Received for publication February 27, 2013; revision received September 7, 2013. DOI: 10.1097/PSY.0000000000000013 800
concluded that somatoform symptoms and psychiatric comorbidity may have acted together to produce suicidality in patients with unexplained pain. The idea that somatoform symptoms might play a role in the development and perpetuation of suicidality is in line with the cognitive model of suicidality introduced by Wenzel and Beck (17). According to their model, dysfunctional cognitive processes that are associated with the specific symptoms of patients can activate suicidal ideation, depending on the general level of stress and dispositional vulnerability of patients. These processes include biases in what patients believe about themselves and others as well as how they process new information. Wenzel and Beck (17) refer to the term cognitive content specificity in this context to make clear that the content of these cognitive processes varies depending on the specific symptoms of patients. Knowledge about the symptom-specific cognitive processes might thus help to trace pathways for the development of suicidality in patients with somatoform disorders, with vital implications for the prevention and management of suicidality in these patients. In patients with somatoform disorders, these cognitive biases may largely consist of dysfunctional illness perceptions that play a central role in cognitive behavioral models of medically unexplained symptoms. These models state that patients develop a belief that their physical symptoms are chronic and uncontrollable because physicians fail to find a pathophysiological cause for their suffering (18). Consistently, these patients tend to perceive many negative consequences in association with their unexplained symptoms including negative emotional responses such as depression and anxiety. Biases in the processing of new information are also of relevance, for example, in the context of attentional focusing of patients on their physical symptoms (19). Following the model of Wenzel and Beck (17), more extreme levels of these dysfunctional illness perceptions might facilitate suicidality in patients with somatoform disorders. The goals of the present study were a) to examine the rate of suicidality in primary care patients with somatoform disorders and (b) to identify factors that might help to understand and manage suicidal ideation in these patients. Based on the cognitive Psychosomatic Medicine 75:800Y806 (2013)
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SUICIDALITY AND SOMATOFORM DISORDERS METHODS Design and Sample
Figure 1. Flowchart of the study design including numbers of patients.
models of suicidality (17) and medically unexplained symptoms (18,19), we hypothesized that there is a significant relationship between the intensity and duration of dysfunctional illness perceptions on the one hand and the occurrence of active suicidal ideation on the other hand. Following these models, we expected that dysfunctional illness perceptions would contribute to the understanding of suicidal ideation in patients with somatoform disorders, independent of relevant psychiatric comorbidity and previous suicidal behavior.
We conducted a cross-sectional study with 41 general practitioners (GPs) at 19 locations. These GPs participated in a large regional research project (20) designed to improve the health care situation of patients with mental disorders in the Hamburg metropolitan area (Northern Germany). All GPs were visited on 2 to 4 days, depending on the size of the general practice. On these days, patients were asked in a consecutive order to answer a short questionnaire about their health status. All patients provided oral informed consent for an anonymous screening. Patients who were interviewed by telephone also provided written informed consent. The protocol for the study was approved by the ethics ¨ rztekammer Hamburg). Patients who committee of the local medical council (A were not able to fill in the screening questionnaire or to participate in a telephone interview because of physical or psychiatric impairment, patients with substantial language problems, and patients who were younger than 18 years were excluded. Data were collected between September 2011 and February 2012. A detailed chart of the patient flow is depicted in Figure 1. Of the 1882 primary care patients who were eligible for an anonymous screening of their symptoms in the context of our study, 1645 (87%) agreed to participate. Patients with severe somatic complaints (Patient Health Questionnaire [PHQ]-15) and patients with moderate somatic complaints in combination with at least moderate symptoms of depression (PHQ-9) and/or anxiety (Generalized Anxiety Disorder [GAD]-7) were asked to participate in a subsequent telephone interview to validate the somatoform character of the symptoms and to explore suicidality and illness perceptions. These patients were chosen in the context of the original research project because they were considered to be in need for adequate management of their symptoms (20). GPs completed a checklist for these patients in which somatic comorbidity and psychotropic drug intake (including pain medication) was documented. It was also assessed whether GPs had recommended specialized help by a mental health care professional to their patients. Of all patients who were asked for the telephone interview (n = 267), 156 (58%) ultimately participated. The mean (standard deviation) time between screening and telephone interview was 4.7 (2.4) weeks. Nonresponse analyses revealed that there were no significant differences in age, sex, and screening results between those patients who participated in our telephone interview and those who did not participate (data not shown). A total of 142 patients fulfilled the lifetime criteria for somatoform disorders according to the somatoform section of the Composite International Diagnostic Interview (CIDI), which implied that patients were experiencing a somatoform disorder at least once in their life. Twenty-four of these patients reported in this interview that the last episode of their somatoform symptoms occurred longer than 6 months before the current assessment. Based on the positive PHQ-15 screening results of these patients, which reflect clinically relevant symptoms during the previous 2 weeks, we considered the symptoms of these patients to be current as well and included these patients in our study. Most of the patients with a somatoform disorder were experiencing a somatoform pain disorder (n = 97) or an undifferentiated somatoform disorder (n = 43). Two patients had a somatization disorder. These 142 patients were included in the examination of suicidality rates in primary care patients with somatoform disorders (i.e., the first goal of our study). Because of missing data, we excluded six patients from the analyses that were conducted to identify factors that might help to understand and manage active suicidal ideation in these patients (i.e., the second goal of our study).
TABLE 1. Assessment of Suicidality During the Telephone Interview Type Ideation
Attempt
Content
Response
Have you thought about ending your life during the past 6 mo?
Yes/No
If yes, did you or have you made any specific plans to commit suicide?
Yes/No
If yes, did you or have you made any preparations to commit suicide?
Yes/No
Have you ever actively tried to end your life?
Yes/No
If yes, when did this attempt take place (first if more than one)?
Psychosomatic Medicine 75:800Y806 (2013)
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date
801
J. F. WIBORG et al. Instruments The PHQ was used to screen somatic complaints (PHQ-15) as well as comorbid symptoms of depression (PHQ-9) and anxiety (GAD-7) in general practice (21,22). On all subscales of the PHQ, a cutoff score of 10 (or higher) was used to indicate moderate symptoms and a cutoff score of 15 (or higher) was used to indicate severe symptoms. The latter cutoff has good sensitivity, while maximizing specificity for the identification of comorbid disorders of depression and anxiety (23). The PHQ-9 includes a suicidality item that asks for thoughts about being better off dead or hurting oneself. We used the PHQ-8 depression scale in subsequent analyses, which omits this suicidality item. Items that were left unanswered were interpreted as not relevant for the patient (i.e., calculated as zero in the sum scores). Cronbach > reliability coefficients have been shown to be .89 to .92 for the GAD-7, .79 to .80 for the PHQ-15, and .86 to .89 for the PHQ-9 with similar operating characteristics for the PHQ-8 (21Y23). In our study population, we found reliability coefficients of > = .90, .77, and .88 for the GAD-7, PHQ-15, and PHQ-9, respectively, with identical coefficients for the PHQ-9 and the PHQ-8 (i.e., .88). The somatoform section of the computerized lifetime version of the CIDI was used to validate our screening results and diagnose a somatoform disorder (24). In this section, patients first rate the severity of their physical symptoms and are then asked whether their symptoms were attributed to a physical condition, medication, or the use of drugs or alcohol by a medical professional. Patients with somatic comorbidity can qualify for a somatoform diagnosis in this section as long as their comorbidity is not the exclusive explanation for their complaints. Preoccupation with illness is also assessed. Interrater reliability of all CIDI sections has been shown to be good, with k values of 0.81 or higher (24). The computerized and telephone-administered CDI interviews were conducted by specifically trained medical students in the context of their doctoral dissertation. The assessment of suicidality was based on recommendations by Po¨ldinger (25) and included a set of standardized questions that were assessed by telephone (Table 1). All patients who answered the first question about suicidality with yes (i.e., those who thought about ending their life during the previous 6 months) were defined as suicidal ideators in subsequent analyses. Patients with acute suicidality were presented to a trained clinician by the interviewers after the telephone interview had been finished. The clinician decided about further actions. The Brief Illness Perception Questionnaire (BIPQ) was used to assess dysfunctional illness perceptions during the telephone interview (26). This version is based on the work of Weinman et al. (27) and Moss-Morris et al. (28). In the BIPQ, eight ordinal scales (0Y10) are used to asses eight different illness perceptions, including consequences, timeline, personal control, treatment control, identity, concern, understanding, and emotional response. The BIPQ has been shown to have adequate test-retest reliability with correlation coefficients between .48 and .70 at a 3-week reassessment of the single items (26). An overall sum score from all eight items was computed to represent the degree to which the complaints are perceived as problematic (higher scores represent more negative illness
perceptions) (29). Items 3, 4, and 7 were reverted for this purpose. We found a Cronbach > reliability coefficient of .68 for the sum score of the BIPQ in our sample.
Statistical Analysis Ninety-five percent confidence intervals for single proportions were calculated using the Wilson Score Method (30). Univariate differences between patients with and patients without suicidal ideation were tested using the MannWhitney U and Fisher exact tests. Next, we tested two consecutive models using multiple logistic regression analysis with active suicidal ideation as a dependent variable. In the baseline model, we included psychiatric comorbidity (i.e., comorbid symptoms of depression and anxiety) and previous suicide attempts as independent variables. In the second step, we added the sum score of dysfunctional illness beliefs (BIPQ) as an indicator of the intensity of the symptomspecific dysfunctional beliefs and the age of onset of the somatoform disorder as an indicator of the duration of the beliefs. We expected that the somatoformspecific factors would yield significance when they are controlled for the factors of the baseline model. In addition, we assumed that the total explained variance (Nagelkerke R2) of the first model would increase by entering the somatoformspecific factors. All tests were two sided, and the threshold for statistical significance was set at p e .05.We used SPSS (version 20) for our computations.
RESULTS We included 142 primary care patients with somatoform disorders (Fig. 1). The median age of these patients was 45.5 (18Y84) years, and 82% were female. GPs indicated that 23 (16%) of the 142 included patients were already receiving additional treatment by a mental health care professional and that they had recommended referral to such a professional in 39% (n = 46/119) of the remaining patients (no answer was interpreted as no treatment or referral). According to the GPs, 21% of the 142 patients were taking antidepressant medication; 13%, pain medication; 4%, benzodiazepines; and 2%, antipsychotic medication. At the time of the screening, 53 (37%) of the 142 included patients were bothered by thoughts of being better off dead or hurting oneself, according to the PHQ-9 suicidality item. The proportion of patients with a negative screening result who endorsed the suicidality item of the PHQ-9 was 90 (7%) of 1378 patients. The difference in proportion between the two groups was statistically significant ( p G .001), according to the Fisher exact test. Thirty-six (37%) of 97 patients with a somatoform pain disorder and 17 (40%) of 43 patients with an
TABLE 2. Suicidality Rates in Patients With Somatoform Disorders (n = 142) n
%
95% CI
53
37.3
29.8Y45.5 17.7Y31.6
Screening Thoughts of being better off dead or hurting oneself (PHQ-9) Interview Active suicidal ideation (past 6 mo)a
34
23.9
Concrete plans for suicidal act
10
7.0
3.9Y12.5
Preparations for suicidal act Previous suicide attempt (lifetime)b
2 25
1.4 17.6
0.4Y5.0 12.2Y24.7
Any suicidality reported during interviewa,b
46
32.4
25.2Y40.5
PHQ = Patient Health Questionnaire; CI = confidence interval. a Two patients declined to answer any questions about suicidality. b Two additional patients declined to answer questions about suicide attempts. 802
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SUICIDALITY AND SOMATOFORM DISORDERS TABLE 3. Univariate Testing of Differences Between Patients With and Without Suicidal Ideation Totala (n = 136)
No Suicidal Ideation (n = 106)
Suicidal Ideation (n = 30)
p
Ageb
45.5 (18Y84)
45.0 (18Y84)
46.0 (18Y82)
.92
Women
112 (82%)
85 (80%)
27 (90%)
.28
Married
46 (34%)
36 (34%)
10 (33%)
.99
76 (56%)
62 (59%)
14 (47%)
.30
10 (7%)
10 (9%)
0 (0%)
.12
1 (1%)
1 (1%)
0 (0%)
.99
Demographic
Employed Somatic comorbidity Coronary heart disease Multiple sclerosis Diabetes
14 (10%)
11 (10%)
3 (10%)
.99
COPD
9 (7%)
7 (7%)
2 (7%)
.99
Cancer
6 (4%)
4 (4%)
2 (7%)
.61
Arthritis
1 (1%)
1 (1%)
0 (0%)
.99
Psychiatric comorbidity Depression according to PHQ-8 None or mild (G10)
37 (27%)
33 (31%)
4 (13%)
.06
Moderate (Q10 and G15)
57 (42%)
49 (46%)
8 (27%)
.06
Severe (Q15)
42 (31%)
24 (23%)
18 (60%)
G.001
Anxiety according to GAD-7 None or mild (G10)
42 (31%)
35 (33%)
7 (23%)
.38
Moderate (Q10 and G15)
55 (40%)
48 (45%)
7 (23%)
.036
39 (29%) 25 (18%)
23 (22%) 12 (11%)
16 (53%) 13 (43%)
.001 G.001
15.0 (2Y66)
15.0 (2Y66)
14.0 (3Y43)
.032
5.0 (0Y10)
5.0 (0Y10)
7.0 (2Y10)
G.001
Severe (Q15) Previous suicide attempt Somatoform specificb Age onset symptoms BIPQ-consequences BIPQ-timeline
7.0 (0Y10)
6.0 (0Y10)
9.0 (0Y10)
.034
BIPQ-personal control
5.0 (0Y10)
5.5 (0Y10)
5.0 (0Y10)
.013
BIPQ-treatment control
7.0 (0Y10)
6.0 (0Y10)
7.0 (0Y10)
.51
BIPQ-identity BIPQ-concern
7.0 (0Y10) 5.0 (0Y10)
6.0 (0Y10) 5.0 (0Y10)
7.5 (4Y10) 6.5 (0Y10)
.005 .044
BIPQ-understanding
8.0 (0Y10)
8.0 (0Y10)
8.0 (0Y10)
.79
BIPQ-emotional response
7.0 (0Y10)
7.0 (0Y10)
9.0 (3Y10)
.001
COPD = chronic obstructive pulmonary disease; PHQ = Patient Health Questionnaire; GAD = Generalized Anxiety Disorder; BIPQ = Brief Illness Perception Questionnaire. Differences were tested with Mann-Whitney or Fisher exact test. a Six patients were excluded because of missing data. b Median scores (range).
undifferentiated somatoform disorder endorsed the suicidality item of the PHQ. In total, 46 patients reported about any suicidality during the telephone interview (Table 2). Two patients declined to answer any questions about suicidality, and two additional patients declined to answer questions about suicide attempts. All suicidality rates were based on the total sample of 142 included patients (missing values were interpreted as no suicidality). Most of the patients with suicidality had experienced active suicidal ideation during the previous 6 months. Of the 34 patients who answered positively to the active suicidal ideation item during the telephone interview, 29 (85%) patients had also endorsed the suicidality item of the PHQ-9 during the screening. Twenty-seven (28%) of 97 patients with a somatoform pain
disorder and 7 (16%) of 43 patients with an undifferentiated somatoform disorder reported about active suicidal ideation during the interview. Ten (7%) patients had concrete plans for a suicidal act during the same period. Twenty-five (18%) patients had previously engaged in a suicidal act. Most of these patients (n = 20/25) tried to commit suicide after onset of the somatoform symptoms. Univariate testing of differences between patients with and patients without suicidal ideation is presented in Table 3. Six patients were excluded from these and subsequent analyses because of missing data with respect to suicidality (n = 4) or illness perceptions (n = 2). According to our analyses, both groups did not differ significantly on demographic variables and somatic comorbidity. However, patients with suicidal ideation reported
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803
J. F. WIBORG et al. TABLE 4. Multiple Logistic Regression Analysis With Suicidal Ideation as a Dependent Variable (n = 136) Model 1, OR (95% CI) Previous suicide attempt
(1 = yes)
Level of comorbid depression (PHQ-8; range = 2Y24) Level of comorbid anxiety (GAD-7; range = 0Y21) Age onset somatoform symptoms (range = 2Y66 y) Dysfunctional illness perceptions (BIPQ sum; range = 1Y78)
3.02* (1.06Y8.62)
Model 2, OR (95% CI) 2.65 (0.90Y7.87)
1.17* (1.03Y1.33)
1.15* (1.00Y1.32)
1.02 (0.90Y1.16)
1.01 (0.88Y1.15) 0.98 (0.94Y1.02) 1.06* (1.01Y1.11)
PHQ = Patient Health Questionnaire; GAD = Generalized Anxiety Disorder; BIPQ = Brief Illness Perception Questionnaire; OR = odds ratio; CI = confidence interval. Six patients were excluded because of missing data. * p e .05.
significantly more severe comorbid depression and anxiety and were significantly more likely to have a history of suicide attempts compared with patients who did not have suicidal ideation. Patients with suicidal ideation also had a significantly earlier onset of somatoform symptoms and had significantly more dysfunctional illness perceptions. In particular, these perceptions included the idea that the physical symptoms had a profound negative effect on their life and would last a long time, with little chance to control them, while experiencing more negative emotions in reaction to these symptoms. Multiple logistic regression analysis was then conducted to test two different models with active suicidal ideation as a dependent variable (Table 4). In our baseline model, comorbid symptoms of depression and previous suicide attempts were significantly associated with suicidal ideation. Comorbid symptoms of anxiety did not yield significance in this model. In an additional step, we added age of onset of the somatoform symptoms and the overall sum score of the BIPQ to the baseline model. Comorbid depression and dysfunctional illness perceptions were both significantly associated with suicidal ideation in our complete model. Comorbid symptoms of anxiety, previous suicide attempts, and age of onset of the somatoform symptoms did not reach significance in this model. The additional step and both models were significant ( p G .05). Nagelkerke R2 increased from 0.272 in the first to 0.332 in the second model. DISCUSSION The present study is the first one, to our knowledge, that has examined suicidality in primary care patients with somatoform disorders. According to our data, suicidality seems to be a substantial problem in these patients. In the general medical population, the rate for suicidal ideation ranges between 1% and 10%, depending on how it is assessed, but can exceed 30% in patients with major depression (31,32). Rates of passive death wishes are usually higher than rates of active suicidal ideation. In line with previous studies, we found that the rate of suicidal ideation assessed with the PHQ (37%), which included passive death wishes, was higher than the rate of active suicidal ideation (24%), which was assessed during the telephone interview. In our sample of patients with 804
a negative screening result, the PHQ rate of suicidality was significantly lower (i.e., 7%). Ten of the 142 patients with a somatoform disorder actually had concrete plans for committing suicide. In total, our suicidality rate was lower than that of psychiatric outpatients with somatoform disorders reported by De Klerk et al. (15). They found a total rate of 45% but included lifetime suicidal ideation and self-harm behavior without suicidal intent. Many of our patients with active suicidal ideation reported about severe depression or anxiety as indicated by PHQ-8 and GAD-7 scores of 15 or higher. Patients with such high scores are most likely experiencing a comorbid depression or anxiety disorder (23), which suggests that psychiatric comorbidity is a prominent feature of somatoform patients with suicidal ideation. This finding is in line with a previous study about suicidality in patients with unexplained pain (16). The significant factor of our regression models with respect to psychiatric comorbidity was the level of depressive symptoms. In addition, we found that the level of dysfunctional illness perceptions was significantly related to active suicidal ideation independent of psychiatric comorbidity and previous suicidal behavior. This finding may suggest that knowledge about cognitions that are specific to the symptoms of patients may, in fact, help to trace individual pathways of suicidality, as suggested by the cognitive model of suicidality (17). Our findings do not support the idea that suicidal ideation in patients with somatoform disorders is merely a consequence of psychiatric comorbidity and has nothing to do with the symptom-specific cognitive processes of these patients. Generally, our cross-sectional exploration of potential factors of suicidal ideation should be understood as preliminary. Future studies need to replicate and extend our findings. Such studies should focus on longitudinal data collection to enhance the understanding of the course of suicidality in patients with somatoform disorders and thereby help to elucidate whether an increase in intensity in somatoform-specific cognitive processes actually precedes the occurrence of suicidal ideation in these patients. At the same time, other potentially influential variables should be included in these studies. One of the priorities would be to better understand the role that general levels of stress and dispositional vulnerabilities play in the development of suicidal ideation in patients with somatoform disorders. Psychosomatic Medicine 75:800Y806 (2013)
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SUICIDALITY AND SOMATOFORM DISORDERS Following the model of Wenzel and Beck (17), hopelessness could be tested as a potential mediator of the relationship between somatoform-specific dysfunctional cognitive processes and suicidal ideation. Patients with somatoform disorders might thus come to the conclusion that their situation is hopeless and engage in suicidal ideation because they have developed extremely dysfunctional beliefs about their unexplained physical symptoms. If this assumption holds true, it may convey an important lesson for the prevention and treatment of suicidality that is not self-evident when clinicians are solely referred to the psychiatric comorbidity of these patients. This lesson encompasses the relative importance of somatoform-specific cognitive contents in the management of suicidality in patients with somatoform disorders in contrast to other patient populations such as patients with major depression without a history of somatoform disorders. Specific interventions for dysfunctional illness perceptions (33,34) could be further elaborated and tested in this context. Apart from the cross-sectional design of our study, there are also other potential limitations. We had to exclude patients with moderate somatic complaints who had no or only mild levels of comorbid depression and anxiety because of the design of the original research project from which our data were derived (20). This research project focused on primary care patients who were most likely in need for help by a mental health care professional. If psychiatric comorbidity is, in fact, a prominent feature of suicidal patients with somatoform disorders, rates of suicidality might be lower in the group of excluded patients who do not have clinically relevant levels of depression and anxiety. Patient attrition may also have biased the findings of this study. In particular, substantial loss of participants appeared among patients with a positive screening result. Nonresponse analysis suggested, however, that such a bias is no likely explanation for our findings. The total rate of positive screening results of 16% (n = 267/1645) as an indicator for the frequency of somatoform disorders in our study population is thereby in line with a Dutch study about the prevalence of somatoform disorders in primary care (10). Although we were not able to validate the somatoform character of the physical symptoms in all of the 267 patients because of attrition, most of the positively screened patients who participated in our telephone interview also fulfilled lifetime criteria for a somatoform disorder (i.e., 990%). In general, the cutoff score on the PHQ-15 used in this study has been shown to be a good indicator for detecting somatoform disorders in primary care patients (35). We included all patients with a lifetime history of a somatoform disorder based on their PHQ-15 screening results. This strategy may have inflated the rate of current somatoform disorders in our study. This effect might have been further increased by the fact that we did not include the complete CIDI interview but focused on its somatoform section instead. However, other studies suggest that our total rate of 16% is within the lower rather than the higher area of estimated prevalence rates for current somatoform disorders in primary care settings (10Y12). Potential overdiagnosing of somatoform disorders is also a general problem of structured diagnostic interviews such as the CIDI (24). A
modified classification of these disorders in the upcoming Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, may help to increase reliability (36). Using the sum score of the BIPQ rather than its individual items might not have been the ideal strategy to determine the relative importance of each of these dimensions in understanding suicidal ideation in patients with somatoform disorders. However, we think that there are several advantages associated with this strategy in the context of our study. The sum score might generally better reflect the overall intensity of dysfunctional cognitive processes, as described by Wenzel and Beck (17). In addition, the sum score is easier to handle statistically because it can also be tested in samples with restricted size while avoiding the problem of multicollinearity among single items. That we conducted the BIPQ by telephone might have biased the response of our patients in comparison with the selfadministered variant of the questionnaire. It seems unlikely, however, that variables such as social desirability play a vital role in the administration of the BIPQ. Unfortunately, we were not able to collect data about the recognition of suicidality by GPs in our sample. Our finding that only about half of the patients either were in treatment by a mental health professional or had received a recommendation for referral to such treatment seems in line with previous research showing that many GPs are ambivalent about medically unexplained symptoms and the potential of mental health care providers to treat patients with these symptoms effectively (37). At the same time, the rate for treatment by a mental health care professional or recommendation for referral to such a professional was considerably higher in patients who engaged in active suicidal ideation (i.e., 77% as opposed to 49%). This finding may suggest that GPs are generally sensitive to the severity of individual cases. Based on our findings, GPs may want to use patients’ routine reports about how they perceive their physical complaints as an additional cue for identifying active suicidal ideation in patients with somatoform disorders. In particular, those patients may engage in suicidal ideation who report about a severe impact of the physical symptoms on their life including intense negative emotional responses, little perceived control, and the expectation that the symptoms will last a long time. Based on these and upcoming insights, specific interventions for the management of suicidality in patients with somatoform disorders could be developed and tested as part of evidence-based practice for these patients. We thank Dr. Alexandra Murray for her critical review of the manuscript. Source of Funding and Conflicts of Interest: The study from which the data for this article were derived was funded by the German Federal Ministry of Education and Research (principal investigator: B.L.). The funding source had no formal role in the interpretation of the data or preparation of the manuscript. All authors declare the following: no support from any organization (other than mentioned as funding) for the submitted work, no financial relationships with any organizations that might have an interest in the submitted work in the previous 3 years, and no other relationships or activities that could seem to have influenced the submitted work.
Psychosomatic Medicine 75:800Y806 (2013)
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Psychosomatic Medicine 75:800Y806 (2013)
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