Suicide Risk 10-Fold Higher in Women With Fibromyalgia

Janis C. Kelly

October 15, 2010

October 15, 2010 — Women with fibromyalgia have a 10-fold increased risk for suicide and are also at increased risk for liver disease and cerebrovascular disease, Danish researchers report in the October issue of Arthritis & Rheumatism.

Drawing on Danish hospital and mortality data, Lene Dreyer, MD, PhD, and colleagues found that although overall mortality among patients with fibromyalgia was not increased, there were increased risks for women. This was the first prospective study of mortality in fibromyalgia to include a clinical examination at the hospital, a blinded review of the diagnosis according to American College of Rheumatology criteria, data from a complete national death registry, and up to 16 years of follow-up.

"The suicide risk was increased at the time of diagnosis and remained increased after 5 years," the authors write.

The 84 male patients included did not have increased cause-specific mortality.

The analysis showed that among the 1269 female patients with fibromyalgia, the standardized mortality ratios were 10.5 for death from suicide, 6.4 for death from liver cirrhosis or biliary tract disease, and 3.1 for death from cerebrovascular disease. After a mean follow-up of 3.9 years, there had been 48 deaths observed among 1353 patients (84 men, 1269 women). The 41 deaths among 1269 women with fibromyalgia included 8 from suicide, 8 from cancer, 6 from liver cirrhosis/biliary tract disease, 6 from cerebrovascular disease, 4 from chronic obstructive pulmonary disease, 3 from other heart disease, 2 from other causes, and 1 each from ischemic heart disease, pneumonia, mental disorders, and other external causes.

Immediate Clinical Implications

This study has immediate clinical implications, expert say.

"Risk factors for suicide should be sought at the time of the diagnosis of [fibromyalgia] and at follow-up. The results also suggest that risk factors for liver disease and cerebrovascular disease should be evaluated in patients with [fibromyalgia]," Dr. Dreyer, who is at Copenhagen University Hospital in Denmark, and colleagues write.

The authors suggest that the increased risk for suicide might be related to increased rates of lifetime depression, anxiety, pain, fatigue, and psychiatric disorders seen in this population.

Frederick Wolfe, MD, from the National Data Bank for Rheumatic Diseases in Wichita, Kansas, told Medscape Medical News that his group will be presenting similar data on fibromyalgia and suicide risk at the upcoming American College of Rheumatology meeting. Medscape Medical News asked Dr. Wolfe to review the Dreyer study.

"I believe Dreyer's suicide data are correct, but 10-fold increase seems high," Dr. Wolfe said.

He also emphasized that the suicide risk is increased but is very small.

"Among depressed fibromyalgia patients in our study, there were very, very few suicides. Clinicians should listen to the patient and decide if there is a serious mood disorder," Dr. Wolfe said.

David A. Fishbain, MD, professor of psychiatry and adjunct professor neurological surgery and anesthesiology at the University of Miami, Florida, also reviewed the study for Medscape Medical News. Dr. Fishbain, who is an expert on suicidality in patients with chronic pain, said that the Danish results are consistent with a wide body of data from research on suicide in patients with chronic pain. "Their data are one of the only studies on suicide completion. These studies are very rare," Dr. Fishbain said.

A wide body of pain literature has demonstrated that patients with chronic pain (such as those with fibromyalgia) are at higher risk than nonpain patients and the general population for suicide completion, attempts, and ideation, he pointed out.

"Because chronic pain patients are at greater risk for all forms of suicidality, every such patient should be evaluated carefully for suicide ideation," Dr. Fishbain said. He added that the American Psychiatric Association now includes the presence of chronic pain as a suicide risk factor in its guidelines on the evaluation and treatment of suicidality.

Jittender Sareen, MD, who also studies suicidal ideation and suicide attempts in chronic pain conditions, told Medscape Medical News that the increased suicide risk should be interpreted in context.

"It is important to note that although the [standardized mortality ratio] was 10 times higher than normal, the vast majority of people with fibromyalgia did not die by suicide. However, clinicians should screen for depression and suicide," Dr. Sareen said.

He added, "Overall, I think this is a well-constructed study. The major strength is that they had clinician-diagnosed fibromyalgia. The major limitation is that mental disorders were not adjusted for in the analysis. The major risk factor for suicide is mental disorders, and fibromyalgia co-occurs with these conditions." Dr. Sareen is at the University of Manitoba, Canada.

The study authors and commentators have disclosed no relevant financial relationships.

Arthritis Rheum. 2010;62:3101-3108. Abstract

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