Outpatient Engagement and Predicted Risk of Suicide Attempts in Fibromyalgia

Objective Patients with fibromyalgia (FM) are 10 times more likely to die by suicide than the general population. The purpose of this study was to externally validate published models predicting suicidal ideation and suicide attempts in patients with FM and to identify interpretable risk and protective factors for suicidality unique to FM. Methods This was a case-control study of large-scale electronic health record data collected from 1998 to 2017, identifying FM cases with validated Phenotype KnowledgeBase criteria. Model performance was measured through discrimination, including the receiver operating area under the curve (AUC), sensitivity, and specificity, and through calibration, including calibration plots. Risk factors were selected by L1 penalized regression with bootstrapping for both outcomes. Secondary utilization analyses converted time-based billing codes to equivalent minutes to estimate face-to-face provider contact. Results We identified 8,879 patients with FM, with 34 known suicide attempts and 96 documented cases of suicidal ideation. External validity was good for both suicidal ideation (AUC 0.80) and attempts (AUC 0.82) with excellent calibration. Risk factors specific to suicidal ideation included polysomatic symptoms such as fatigue (odds ratio [OR] 1.29 [95% confidence interval (95% CI) 1.25-1.32]), dizziness (OR 1.25 [95% CI 1.22-1.28]), and weakness (OR 1.17 [95% CI 1.15-1.19]). Risk factors specific to suicide attempt included obesity (OR 1.18 [95% CI 1.10-1.27]) and drug dependence (OR 1.15 [95% CI 1.12-1.18]). Per utilization analyses, those patients with FM and no suicidal ideation spent 3.5 times more time in follow-up annually, and those without documented suicide attempts spent more than 40 times more time face-to-face with providers annually. Conclusion This is the first study to successfully apply machine learning to reliably detect suicidality in patients with FM, identifying novel risk factors for suicidality and highlighting outpatient engagement as a protective factor against suicide.