Exploring the relationship between pain and suicidality in adolescence
Keywords: young people
suicidality
adolescence
self-harm
pain

Across the world, physical pain (‘pain’) and suicidal thoughts and behaviours (‘suicidality’) are major health concerns in adolescents. Emerging research in adults and leading suicide theories recognise pain as an important correlate for suicidality. Although prevalence rates of suicidality and pain increase substantially during adolescence, their relationship in adolescence remains poorly understood. Such knowledge is paramount, as the early delivery of effective care may provide an opportunity to prevent long-term suffering and at its worst mortality.
First, I aimed to synthesise the evidence for a relationship between pain and suicidality in adolescence. Second, I aimed to examine this relationship in two independent samples of young people. By using state-of-the-art statistical analyses ((moderated) network analyses and latent class growth analyses), I controlled for shared correlates, explored if specific subgroups may be at an increased risk for this association and how this association may unfold throughout the adolescent years. Third, I aimed to shed light on service use in adolescents with pain and/or suicidality.
My systematic review revealed support for the pain-suicidality association in adolescents across community and clinical samples and types of pain and suicidality. However, the sparsity of high-quality evidence emphasised the need for further research.
In two independent samples, I have shown that pain and suicidality are common experiences in young people, especially in adolescents, in the United Kingdom. Pain was cross-sectionally associated with a two- to fourfold increased risk of suicidality and vice versa, with no differences between children (aged 5-9 years) and adolescents (aged 10-16 years), and adolescent boys and girls. This association remained significant in network analyses, after shared correlates of pain and suicidality were accounted for and was not moderated by depression. Furthermore, four longitudinal pain trajectories (increasing, decreasing, and persistent/recurrent probability of pain, and no pain) were identified that were associated with distinct sets of correlates. Crucially, only the persistent/recurrent pain trajectory (vs. no pain) was predicted by baseline suicidality and predicted future suicidality, suggesting a bidirectional pain-suicidality association in young people. Together, these findings demonstrate that pain is an independent correlate of suicidality in adolescence and emphasise screening for suicidality even in the absence of depressive symptoms. However, do adolescents with pain and/or suicidality use health and social services?
In my final data chapter, I aimed to examine this question in a representative sample of adolescents (11-15 years) in the United Kingdom. I showed that 55 percent of adolescents used health and social services, with general practitioner visits, outpatient appointments for injuries, and contacts with a school nurse being the service units used most frequently. Total service use across settings was highest for adolescents with pain-suicidality comorbidity (74% using services), followed by adolescents with pain (68% using services), suicidality (64% using services) and neither pain nor suicidality (49% using services). As no single setting was used by most adolescents (>50%), awareness of the pain-suicidality association is crucial across primary care, hospital, and school settings to aid early risk identification.
Together, my findings have important implications: Theoretically, they inform the development of a working model to uncover risk pathways and mechanisms underpinning the pain-suicidality association in adolescence that may guide future research. Clinically, these findings underscore the need for regular screening and systematic follow-up of vulnerable youth, and the training of healthcare professionals and community staff to recognise suicidal vulnerability in young people with pain or vice versa. In summary, the translational nature of my research leads to valuable recommendations for public mental health initiatives, and clinical research and practice.