Evidence
Alert

People with painful rheumatic conditions are at increased risk of self-harm

People with painful rheumatic conditions such as fibromyalgia, rheumatoid arthritis, and osteoarthritis are at increased risk of self-harm. New research found the risk was highest for those with fibromyalgia, who were twice as likely to harm themselves as people without the condition. 

Rheumatic conditions are characterised by pain in joints, muscles and/or connective tissue. People with fibromyalgia can have pain all over the body and often also experience extreme tiredness, muscle stiffness and difficulty sleeping. 

This research encourages GPs, rheumatologists, and allied health professionals to be more alert to the mental health of their patients, particularly those with fibromyalgia and rheumatoid arthritis. The researchers suggest that, if concerned, primary care clinicians should assess their patients’ mood and risk of self-harm, soon after diagnosis. This group of patients may need psychological support. 

The level of self-harm in people with these conditions has remained unchanged over the last 16 years. More could be done to identify mental health needs in people with these conditions, the study concludes.

What’s the issue?

Rheumatic conditions affect muscles, joints, and connective tissue. In many of these conditions, the person’s immune system attacks these parts of their body and the inflammation causes damage and pain. 

Some rheumatic conditions are more common in older people, but they can affect all age groups. There are no cures, only treatment and management. For some people, with some of these conditions, simple tasks such as walking, bathing, and getting dressed are painful and difficult

Long-term pain can increase the risk of self-harm, and its prevention is an international public health priority. The World Health Organization recommends that healthcare professionals consider the potential for self‐harm in patient groups with chronic pain and depression – which includes many people with rheumatic conditions. 

This is the first study to explore whether living with a rheumatic condition increases the risk of self-harm.  Researchers focused on four common conditions often linked to depression and pain:

  1. Fibromyalgia, which causes widespread pain, fatigue, muscle stiffness, headaches, and problems with memory, concentration and sleeping. It is difficult to diagnose and it is not known how many people have this condition. However, it is more common in women, and is estimated that one in 20 people have some degree of fibromyalgia. 
  2. Rheumatoid arthritis, which causes painful, swollen, and stiff joints, often in the hands, feet, and wrists. It can lead to other problems, such as fatigue and weight loss. It affects more than 400,000 people in the UK. Women are three times more likely to be affected as men
  3. Osteoarthritis, which causes joint pain and stiffness, often in the knees, hips, and hands. It is the most common type of arthritis in the UK, affecting nearly 9 million people.
  4. Ankylosing spondylitis, which usually causes back pain and stiffness, fatigue, and pain and swelling elsewhere in the body. Around 200,000 people in the UK have been diagnosed with the condition.

What’s new?

Researchers analysed data from the Clinical Practice Research Datalink (CPRD), the largest primary care dataset in the UK. They included adults recorded as having fibromyalgia (17,546 cases), rheumatoid arthritis (23,205 cases), osteoarthritis (410,384 cases), or ankylosing spondylitis (10,484 cases) between 1990 and 2016. Most people with fibromyalgia, rheumatoid arthritis and osteoarthritis were women (86%, 60% and 67%, respectively). The researchers looked to see if the individuals were recorded as harming themselves in the years following their diagnosis. 

The same number of people without one of these four rheumatic conditions were included as a comparison group. The researchers controlled for other factors which could increase self-harm, including depression, alcohol consumption and deprivation. 

They found that people with fibromyalgia, rheumatoid arthritis, and osteoarthritis were at increased risk of harming themselves. 

    • The incidence of self‐harm was highest in people with fibromyalgia, who were twice as likely to harm themselves as those without the condition. 
    • People with rheumatoid arthritis had an increased self-harm risk of 59%.
    • Unlike the other conditions, with osteoarthritis, people’s risk of self-harm varied according to the time since diagnosis. Those who had had the condition for up to ten years had a slightly increased risk of harming themselves (up to 35%), but those who had had the condition for less than one year or more than ten years were not at increased risk. 
    • No link was found between ankylosing spondylitis and self‐harm.

Neither age nor gender appeared to have a marked effect on the risk of self-harm. And in the 16 years from 2000 to 2016, the rates of self-harm across each rheumatic condition remained roughly the same. 

Why is this important?

Primary care clinicians, rheumatologists, and allied health professionals need to be aware of the potential for self‐harm in people with rheumatic conditions, particularly fibromyalgia and rheumatoid arthritis. They should explore their patients’ mood, ask about self-harm behaviour and offer appropriate support and management.

The finding that people with fibromyalgia are at the greatest risk of harming themselves is in line with previous research. This group has been shown to experience more depression, pain, fatigue, and suicidal thoughts than patients with other rheumatic conditions. 

This could be because they - along with people with rheumatoid arthritis - may experience more widespread pain and a reduced quality of life. This could make them more vulnerable to self-harm. 

Researchers found a lower overall risk of self-harm for people with osteoarthritis. This could be because osteoarthritis causes more localised pain, which has less impact on people's lives. Those with a recent diagnosis have not yet had prolonged experience of pain which may reduce the risk of self-harm. Those with longstanding osteoarthritis may have developed coping strategies which protect them.

What’s next?

Although the results showed no link between the age and sex of the patients and their risk of self-harm, the researchers would like to explore this further with a larger dataset. 

Pain is likely to be an important factor in a person’s risk of self-harm, but it was not reported in the consultation data, and therefore not assessed in this study. The medications taken by people with rheumatic conditions may also affect the risk of self-harm. These factors could be explored in more detail.

Interventions are needed to reduce self-harm in people with rheumatic conditions as rates have changed little in recent years.

You may be interested to read

The full paper: Prior JA, and others. Rheumatic Conditions as Risk Factors for Self‐Harm: A Retrospective Cohort Study. Arthritis Care and Research 2021;73:1  

The National Institute for Clinical Excellence (NICE) clinical guideline on the short-term physical and psychological management and treatment of self-harm.  

NHS advice on how to get help for self-harm

The Mental Health Foundation's booklet: “The truth about self-harm” which explains what self-harm is, what to do if you or someone you know is self-harming, and how to get help

A leaflet from the Royal College of Psychiatrists looking at types of self harm, the help available, how to help yourself and what friends or family can do to help.

Funding

This research was funded by the NIHR School for Primary Care Research and by the NIHR Applied Research Centre West Midlands. 

Commentaries

Study author

It’s perhaps not unexpected that somebody who feels depressed or is in a lot of pain is more likely to self-harm, but the clinicians I’ve spoken to were generally surprised by our findings. This group of patients does not come to mind when you’re thinking about people who might self-harm, compared to people with life-limiting conditions, or diseases likely to have poor outcomes, such as cancer. 

Our research puts the mental health needs of people with rheumatic conditions like fibromyalgia and rheumatoid arthritis on clinicians’ radar. Unless they are having a particular problem, these people may not be seeing a doctor on a regular basis. And if they’re just popping in to get a blood test, they’re not necessarily going to be discussing their mental health. That makes it more important for GPs to address their mental health early on so that they don’t get six months or a year down the line when their mental health has got worse.

James Prior, Lecturer in Epidemiology, Keele University 

Lived experience 

This research outlines a correlation between self-harm and rheumatoid illnesses. But I think the more powerful correlation to seek out is between self-harm and illnesses that are diagnosed late. 

Clinicians encountering self-harming individuals could consider the potential for an illness to be lurking and not yet identified. Fibromyalgia in particular is under-diagnosed, misdiagnosed, or diagnosed late. I myself was not diagnosed for around four years. The symptoms are vague and can be perceived by others as ‘slacking’ or ‘depressed’. The not-yet-diagnosed phase may actually be causing poor mental health and low self-esteem. Self-harming may be the result.

John Owens, Living with fibromyalgia, Loughborough 

Conflicts of Interest

None declared.