In many parts of India, people live with chronic pain and often present it to doctors as a physical symptom for a medical solution. But when the pain persists -- what does it do to one’s mind?

When patients say, “I can’t take this anymore,” the focus often shifts solely to their mental health, missing the underlying physical distress that has been building up for months or even years.

According to the World Health Organization (WHO), India had a suicide mortality rate of 16.5 per 100,000 population in 2016 -- significantly higher than the global average -- with chronic pain emerging as a key risk factor contributing to these deaths.

A growing body of scientific literature, including a recent Lancet Psychiatry study, urge the inclusion of chronic pain as an independent risk factor for suicide in formal risk assessment models. Despite strong neurobiological and epidemiological evidence, chronic pain remains absent from most standardised suicide screening tools -- creating a significant blind spot in clinical practice.

This omission has far-reaching consequences in India, where large segments of the population experience undertreated or unrecognised chronic pain, often without access to psychological support or palliative care -- especially in rural and underserved regions.

Pain is physical, emotional and social

According to Ramdas Ransing, associate professor of psychiatry at AIIMS Guwahati, the relationship between chronic pain and suicide risk is complex and bidirectional -- chronic pain can raise the risk of suicide, while individuals at risk of suicide may be more likely to present with somatic symptoms like persistent pain

“Any pain lasting more than three months is defined as chronic,” says Prarthana Saraswathi, consultant psychiatrist, Rela Hospital, Chennai. “But pain is not just a physical sensation. It’s deeply emotional, especially in contexts like India, where mental health stigma and weak pain management infrastructure leave many patients unsupported.”

Studies from National Institute of Mental Health and Neurosciences (NIMHANS) show a high prevalence of depressive symptoms, hopelessness, and suicidal thoughts among those living with chronic pain. Yet, chronic pain is rarely documented in clinical settings as a psychological concern.

“The focus is overwhelmingly on pain as a bodily issue. Its emotional toll is simply overlooked,” Dr. Saraswathi notes. This often leads to patients expressing passive death wishes rather than overt suicidal ideation. Phrases like “I wish I wouldn’t wake up” or “I’m just a burden to my family” are common -- especially among women suffering from chronic arthritis or lower back pain who feel unable to fulfil caregiving or household roles. Similarly, men with histories of physical labour, upon reaching old age and experiencing immobility, may struggle with self-worth, increased dependence and deepening isolation.

Conventional suicide risk tools miss the mark

Despite these associations, most widely used suicide risk tools -- such as the Columbia-Suicide Severity Rating Scale and the Beck Depression Inventory -- do not include chronic pain as a risk factor, focusing instead on psychiatric symptoms, substance use, and history of self-harm.

“Suicide screening models are still operating through a narrow psychiatric lens,” says Dr. Saraswathi. “They exclude chronic pain because it’s traditionally considered a medical problem.”

This disconnect creates a critical gap in assessment. “Many tools fail to flag high-risk individuals because chronic pain isn’t part of the checklist,” says Mithun Prasad, consultant psychiatrist, SIMS Hospital, Chennai. “But in clinical practice, people with relentless, treatment-resistant pain are more likely to suffer from depression, emotional fatigue, and sometimes suicidal thinking -- especially when pain disrupts sleep, social life and a person’s sense of dignity.”

There is growing recognition that chronic pain and suicidality share overlapping neurobiological mechanisms, involving emotion-regulating circuits such as the anterior cingulate cortex and prefrontal cortex. International studies suggest that even without a formal psychiatric diagnosis, pain alone can significantly increase suicide risk-- making its exclusion from screening protocols a serious oversight.

“Pain doesn’t just live in the body-- it seeps into a person’s identity and their ability to engage with life,” explains Dr. Prasad. “People stop planning for the future. They say things like ‘I’m tired’ or ‘I can’t do this anymore.’ These aren’t casual remarks -- they’re red flags.” He adds that many patients carry their emotional burden silently, especially when they fear burdening family members or appearing weak. This is particularly visible in Indian families, where rigid gender roles, caregiving expectations, and economic dependence can magnify the isolation felt by those in chronic pain.

Barriers -- training gaps and clinical overload

Including pain in suicide risk assessments is not without challenges. “Pain is deeply subjective and varies by etiology -- neuropathic, psychological or inflammatory -- making standardisation difficult,” Dr. Saraswathi notes. Additionally, clinicians may lack training in pain psychology, while pain specialists may not be equipped to assess suicidality. This lack of interdisciplinary coordination often results in fragmented care and missed warning signs.

There is also a practical burden-- adding pain-related indicators could increase consultation time for clinicians already working in overwhelmed systems. Yet, experts agree that the benefits of early identification outweigh these concerns.

In India, socioeconomic vulnerabilities further complicate the issue. “A large portion of the population particularly in rural areas are daily wage workers whose livelihoods depend on physical ability,” says Dr. Saraswathi. “When chronic pain strikes, it doesn’t just cause physical distress. It brings financial insecurity, loss of identity and diminished self-worth induced by social stigma and ableism.”

Yet, suicides triggered by chronic pain are seldom recognised as such in official data. “National Crime Records Bureau (NCRB) reports often cite ‘illness’ as a cause for suicide but don’t disaggregate chronic pain from other medical conditions,” she adds. This under-reporting limits evidence-based policymaking and prevents targeted interventions.

Towards a multidisciplinary model of care

From a public health and policy perspective, including chronic pain in suicide risk assessments could be transformative, says Astik Joshi, child & adolescent and forensic psychiatrist, New Delhi. He advocates for this inclusion across specialties and age groups.

“Pain needs to be acknowledged not just as a medical or psychological issue -- but as a biopsychosocial risk factor,” he says. “Suicide assessment models must move beyond psychiatric diagnoses to account for long-term physical suffering, especially when paired with emotional exhaustion, helplessness, and isolation.”

“Suicide risk assessment should be part of the management and follow-up care in every pain clinic,” Dr. Ransing says, adding that evaluating and addressing chronic pain is equally crucial in the care of those with depression, anxiety, or somatic symptom-related disorders.

Experts propose nationwide capacity-building workshops, integrated pain and mental health clinics and routine cross-referrals between pain specialists and psychiatrists. “A national programme that links chronic pain with suicide prevention is long overdue. With proper training and advocacy, this gap is not insurmountable”, say Dr. Saraswathi

Experts suggest a stepwise reform model: beginning with the early identification of pain through orthopaedic and palliative consultations, followed by integrated assessments -- where emotional wellbeing is routinely screened alongside physical symptoms. Tailored interventions, including counselling, social support and appropriate medication, can ease both the physical and psychological burden.

( Suicide helplines across the country can be accessed here)