Avec un million de décès dans le monde, le suicide est un problème de santé majeur. Malgré la recherche actuelle, les stratégies thérapeutiques efficaces font encore défaut. Les notes de suicide témoignent souvent de la présence d’une douleur intolérable, qu’elle soit physique et/ou psychologique. Les pathologies somatiques en particulier douloureuses sont reconnues comme facteur de risque suicidaire. En outre, malgré la complexité de sa définition, la douleur psychologique semble centrale dans le processus suicidaire. Enfin, considérer l’exclusion sociale (source de la douleur psychologique) peut aussi aider à comprendre la phénoménologie de l’acte suicidaire. La question du rôle de la douleur dans la survenue d’idées et de comportements suicidaires est donc centrale et ouvre de nouvelles voies de compréhension biologique, notamment à travers le système opioïdergique ou l’étude du fonctionnement cérébral. Après avoir exposé les principales données de la littérature permettant de faire le lien entre phénomène douloureux et conduites suicidaires, nous tenterons d’apporter des arguments montrant que l’approche de la problématique suicidaire par l’angle de la douleur et de la déconnexion sociale permet d’envisager des avancées pour améliorer la qualité de l’évaluation du risque suicidaire, pour développer des stratégies thérapeutiques pharmacologiques ou non aux patients suicidaires et pour proposer des actions de prévention.

Intolerable pain is often reported in suicide notes. Moreover, the frequency of life events preceding a suicidal act is high, especially interpersonal difficulties. Such adversity is the source of psychological or social pain.

We propose a narrative review to discuss the role of pain in the suicidal process while having a focus on social ties.

Using Ecological Momentary Assessment in suicide attempters it has been shown that being alone increased suicidal ideation while being with close others significantly reduced this risk. At a neuroanatomical level, suicidal vulnerability is associated with dysfunctional insula activation during social exclusion, a region involved in social and physical pain processing. Social pain elicited by social exclusion or devaluation shares common neurobiological patterns with physical pain. It is also an exemplar of psychological pain. Despite the complexity of its definition, higher psychological pain levels are associated with suicidal ideation and acts. Finally, intense physical pain or chronic pain are strong risk factors of suicidal ideation and act. Interestingly, suicide notes often report the existence of an intolerable pain. Presence of psychological pain and difficulties in communication predict the lethality and seriousness of suicide attempts. Moreover, presence of psychological pain is associated with more impulsive choices in suicidal patients, suggesting that a suicidal act is a means to escape intolerable suffering despite negative long-term consequences (i.e. death). Analgesics are usually used to get relief from pain but are also frequently involved in suicidal overdoses. It has been shown that opioid analgesics are associated with an increased risk of suicide. Higher consumption of opioid analgesics has been shown in suicidal patients in comparison to patients with history of depression but no suicidal act and healthy controls whereas non-suicidal patients were those reporting higher presence of pain in comparison to healthy controls. It may suggest that opioids are being used by suicidal patients to get relief from psychological/social pain rather than from physical pain. Involvement of opioidergic system in suicidal process opens new therapeutic strategies. Recently, the time-limited, short-term use of very low dosages of sublingual buprenorphine (vs. placebo) was associated with decreased suicidal ideation and mental pain in severely suicidal patients without substance abuse. In a randomized controlled trial comparing a 7-week acceptance and commitment therapy (ACT) versus relaxation group, as adjunct to treatment as usual for adult outpatients suffering from a current suicidal behavior disorder, ACT has shown its effectiveness in reducing suicidal ideation and psychological pain. Evidence indicates that maintaining contact either via letter, postcard or telephone with at-risk adults following discharge from care services after a suicide attempt can reduce reattempt risk. Based on these results, a preventive program of recontact for suicide attempters, VIGILANS, has been developed in France in usual care.

The approach of the suicidal issue by the angle of pain and social disconnection offers new advances to improve clinical assessment, to identify new biological pathways involved in suicidal risk, and to propose innovative therapeutic and preventive actions.