Suicidal ideation in patients with chronic pain: The risk-benefit of pharmacotherapy.
Suicidal ideation in patients with chronic pain: The risk-benefit of pharmacotherapy.
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慢性疼痛患者的自杀意念：药物治疗的风险效益。
DOI：
10.1016/j.pain.2014.09.032
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发表时间：
2014
期刊：
影响因子：
7.4
通讯作者：
Cheatle,MartinD
中科院分区：
文献类型：
--
作者：
Cheatle,MartinD
慢性疼痛的患者往往比较复杂，并经常伴有严重的精神并发症。与普通人群相比，经历慢性疼痛的患者有更高的情绪和焦虑症[3，5]，自杀念头的发生在这一患者群体中并不是无关紧要的。2006年的一项系统回顾显示，自杀意念的患病率约为20%，自杀企图的终生患病率在5%至14%之间，与没有疼痛的对照组相比，慢性疼痛患者完全自杀的风险增加了一倍[9]。最近关于疼痛和自杀的文献综述提供了进一步的支持，即疼痛与自杀意念、自杀企图和自杀完成之间存在关联，慢性疼痛患者的自杀意念的患病率从7.92%到40.9%[2]。在疼痛患者的几个亚组中，自杀意念的发生率要高得多。对39例确诊为I型或II型复杂区域疼痛综合征的患者进行了抑郁、疼痛、睡眠和功能评估，其中74.4%的患者被确定为有自杀意念的高危人群[4]。在373名被诊断为纤维肌痛的患者中，48%的样本报告有自杀意念(39.7%的被动性意念和8.3%的主动性意念)。自杀意念与抑郁、焦虑和睡眠障碍相关[1]。慢性疼痛的大量生理、功能和心理后遗症通常需要多模式治疗，包括使用止痛药、抗癫痫药和精神药理药物。尽管已经有大量的学术活动致力于研究处方滥用、滥用和阿片类药物相关过量这一新兴问题，但在疼痛人群中使用的其他药物的潜在有害影响却没有引起太多关注，特别是非阿片类药物与自杀意念之间的联系。Pereira和他的同事[6]进行了一项Medline研究，探索抗抑郁药物和自杀之间的关系。大多数被评估的研究在研究设计、自杀意念的分类和行为方面都有显著的局限性和不一致之处，只有2项研究报告样本中包括慢性疼痛患者，因此作者无法提出具体的结论或建议。此外，Pereira和他的同事[6]认识到，有许多因素导致慢性疼痛患者产生自杀念头和行为，因此分析抗抑郁药对自杀的直接或间接影响是一项艰巨的任务。在此之前，作者对自杀与抗癫痫药物之间的关系进行了类似的综述，受到类似方法学问题的困扰(样本量小，使用不同的研究设计，对自杀缺乏统一的定义)，同样导致了不一致和矛盾的结果[7]。尽管Pereira和他的同事在这一疼痛问题上提出的综述存在局限性，但提出了几个相关的问题。首先，作者强调，对于临床医生来说，重要的是认识到慢性疼痛患者的自杀意念和行为的可能性，并评估开出的药物治疗方案的风险-收益权衡。作者还提供了一些关于某些抗抑郁药潜在致命性的一般指南，并鼓励临床医生根据随机对照试验和副作用描述来选择抗抑郁药。另一个重要的例子是…
Patients with chronic pain tend to be complex and frequently present with significant psychiatric comorbidities. As compared to the general population, patients who experience chronic pain have a higher rate of mood and anxiety disorders [3, 5], and the occurrence of suicidal ideation is not inconsequential in this patient population. A systematic review in 2006 revealed approximately a 20% prevalence rate of suicidal ideation, a lifetime prevalence between 5% and 14% of suicidal attempts, and that the risk of completed suicide was doubled in patients with chronic pain as compared to controls without pain [9]. A more recent review of the literature on pain and suicide provided further support that there was an association between pain and suicidal ideation, suicidal attempts, and suicide completion, and that the prevalence of suicidal ideation in patients with chronic pain ranged from 7.92% to 40.9%[2]. In several subgroups of patients with pain, the incidence of suicidal ideation is substantially higher. Depression, pain, sleep, and function were evaluated in a sample of 39 patients diagnosed with complex regional pain syndrome type I or II. Of this sample, 74.4% were determined to be at high risk for suicidal ideation [4]. In a cohort of 373 patients diagnosed with fibromyalgia, 48% of this sample reported suicidal ideation (39.7% passive ideation and 8.3% active ideation). Suicidal ideation was associated with depression, anxiety, and sleep disorders [1]. The multitude of physical, functional, and psychological sequelae to chronic pain often necessitates a multimodal approach including the use of analgesic, antiepileptic, and psychopharmacologic agents. Although there has been a great deal of scholarly activity devoted to the burgeoning problem of prescription misuse, abuse, and opioid-related overdose, the potential deleterious effects of other pharmacologic agents used in the pain population have garnered less attention, particularly the association between non-opioid medications and suicidal ideation. Pereira and colleagues [6] conducted a Medline search exploring the relationship between antidepressants and suicide. Most of the studies evaluated had significant limitations and inconsistencies in research design, classification of suicidal ideation, and behavior, and only 2 studies reported that patients with chronic pain were included in the sample, thus obviating the authors from rendering specific conclusions or recommendations. Furthermore, Pereira and colleagues [6] recognized that there are numerous factors that contribute to the development of suicidal ideation and behavior in patients in chronic pain, making it a daunting task to parse out the direct or indirect effect of antidepressants on suicidality. Previously the authors conducted a similar review of the association of suicidality and antiepileptic medications, which was plagued with comparable methodology issues (small sample sizes, use of different research designs, lack of uniform definition of suicidality), likewise resulting in inconsistent and contradictory findings [7].Despite the limitations of the review presented by Pereira and colleagues [6] in this issue of Pain, several pertinent issues were raised. First and foremost, the authors emphasized that it is important for clinicians to be cognizant of the potential of suicidal ideation and behavior in patients with chronic pain and to assess the risk–benefit trade-off of the prescribed pharmacotherapy regimen. The authors also provided some general guidelines regarding the potential lethality of certain antidepressants, and encouraged clinicians to select an antidepressant based on randomized controlled trials and side effect profile. Another important …