CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2004;2:1064 –1068
ORIGINAL ARTICLES
Suicidal Ideation in Patients With Irritable Bowel Syndrome
VIVIEN MILLER, LOUISE HOPKINS, and PETER J. WHORWELL
Department of Gastroenterology, South Manchester University Hospitals, Manchester, United Kingdom
Background & Aims: Irritable bowel syndrome (IBS) tra-
ditionally is considered as more of a nuisance than
having especially serious consequences. However, this is
not the picture witnessed in tertiary care where we have
encountered some tragic cases, prompting an assess-
ment of suicidal ideation in such patients. Methods: One
hundred follow-up, tertiary care IBS (tIBS) patients were
compared with 100 secondary IBS (sIBS), 100 primary
IBS (pIBS) care patients, and 100 patients with active
inflammatory bowel disease (IBD). Patients were asked
if they had either seriously contemplated or attempted
suicide specifically because of their bowel problem as
opposed to other issues. The hospital anxiety depression
score was recorded, as were other clinical details on all
patients. Results: A total of 38% of tIBS patients had
contemplated suicide because of their symptoms com-
pared with 16% and 4% in the sIBS and pIBS groups
(tIBS vs. sIBS vs. pIBS, P ⴝ .002, P < .001). The figure
for IBD was 15% (tIBS v. IBD, P < .001). Five tIBS and 1
IBD patient had attempted suicide for gastrointestinal
reasons. Mean depression scores did not exceed thresh-
old (10) in the sIBS group contemplating suicide (9.7),
but were increased in the equivalent tIBS group (11.7).
Hopelessness because of symptom severity, interfer-
ence with life, and inadequacy of treatment were high-
lighted as crucial issues for all IBS patients. Conclusions:
IBS has the potential for a fatal outcome from suicide
with depression not accounting for all the variance in
suicidal ideation. Our observations emphasize the level
of hopelessness felt by these patients and the need for
improvement in the services provided to them.
rritable bowel syndrome (IBS) is the most common
I gastrointestinal condition seen by general practition-
ers and accounts for the majority of the gastroenterolo-
gist’s workload.1–3 Many women with this condition
equate the severity of their pain to that of childbirth and
the bowel dysfunction can be absolutely devastating,
especially when accompanied by incontinence, which is
not that uncommon in patients referred to secondary and
tertiary care. Another problem for sufferers is the noto-
rious inadequacy of treatment, with many medications
offering only marginal benefit.
It recently was shown that the quality of life of indi-
viduals with IBS who are seen in referral centers can be
as bad as that of patients with chronic renal disease or
diabetes,4 and it also has been claimed that the condition
is second only to the common cold in causing absentee-
ism from work.5 Despite all this, IBS frequently is
trivialized and in many industrialized countries it com-
pletely fails to compete with other more “serious” dis-
eases for health care resources, presumably because it is
not perceived as life-threatening.
Clinical experience suggests that suicidal thoughts in
patients with IBS may be induced, at least in part, by the
severity of gastrointestinal complaints. Unfortunately, 2
patients who were followed-up in our clinic recently com-
mitted suicide solely on account of their IBS symptoms
according to their relatives. For this group of relatively
young patients, the prospect of many years of unrelenting
symptoms without hope of relief in the future may be a
significant emotional burden and this may be associated
with a degree of depression. However, it is noteworthy that
it has been suggested that hopelessness, in the context of
there being a lack of any alternative solution to the
patient’s problem, may be a better predictor of suicide
than depression.6 Although suicide and suicidal ideation
have been described in association with chronic nonma-
lignant diseases,7–13 this problem has not been previ-
ously systematically addressed in patients with IBS.
Our aim was to examine the problem of suicidal
ideation in patients with IBS in a tertiary referral clinic
(tIBS), contrasting the results with those from secondary
IBS (sIBS) and primary IBS (pIBS) care and in patients
with active inflammatory bowel disease (IBD), which is
regarded as a more serious organic gastrointestinal dis-
ease.
Abbreviations used in this paper: HAD, hospital anxiety and depres-
sion inventory; IBD, inflammatory bowel disease; IBS, irritable bowel
syndrome; pIBS, primary care irritable bowel syndrome; sIBS, second-
ary care irritable bowel syndrome; tIBS, tertiary care irritable bowel
syndrome.
© 2004 by the American Gastroenterological Association
1542-3565/04/$30.00
PII: 10.1053/S1542-3565(04)00545-2
December 2004 IBS AND SUICIDE 1065

Table 1. Suicidal Ideation and Other Features in Primary, Secondary, and Tertiary Care IBS, and IBD Patients
Primary care Secondary care Tertiary care Significance
group group group Active IBD between groups

Mean age (range) 43.1 (20–67)a 49.2 (17–85) 51.1 (23–83) 45.8 (17–81)a .001
Women % 87 80 84 72 .04
Median disease duration in years (range) 10 (1–57) 10 (1–57) 13 (1–56) 15 (1–53) .008
Suicidal thoughts concerning disease % 4a 16a 38 15a .001
Attempted suicide because of disease % 0 0 5 1 NS
Mean anxiety score—whole group (SD) 8.3 (4.2)a 9.7 (4.4) 10.6 (5.1) 8.7 (4.9)a .003
Mean anxiety score—suicidal thoughts group (SD) 12.2 (5.0) 12.9 (4.6) 14.0 (4.3) 11.7 (4.7) NS
Mean depression score—whole group (SD) 4.1 (3.4)a 6.3 (4.4)a 8.3 (4.9) 5.6 (3.8)a ⬍.001
Mean depression score—suicidal thoughts group (SD) 9.2 (6.1) 9.7 (3.8) 11.7 (4.6) 7.9 (4.6) .048
Symptoms rated as severe % 21a 57 70 40a ⬍.001
Substantial interference with life % 11a 54 71 41a ⬍.001
Treatment considered adequate % 65 48 36 64a ⬍.001
aP ⬍ .05 for comparisons with tertiary IBS group. NS, not significant.

Methods depression questionnaire14 was completed by each patient,

Questionnaires were distributed by 1 of 2 researchers
(V.M., L.H.) consecutively to follow-up IBS patients during
their attendance at our tertiary and secondary care clinics and
to patients in primary care who had never been referred to a
hospital specialist for their gastrointestinal problem. In the
UK hospital care system, tertiary care patients are defined as
those who have been referred from other specialists for a
further opinion as opposed to secondary care referrals, who
initially come from their general practitioners. General prac-
titioners provide primary care for a defined local population of
individuals who can only see a hospital specialist if they are
referred by their general practitioner unless they are already in
the hospital system for a specific complaint. Patients with
active IBD who were attending our secondary care clinic also
were approached. For the purpose of this study, in which the
IBD group served as a comparator for tertiary referral patients
with IBS, those whose disease was minimally active, quiescent,
or in remission were excluded. No patient refused to accept a
questionnaire and all patients were instructed to complete it in
the privacy of their own homes and return it by mail. Ques-
tionnaires were made anonymous immediately on receipt and
all further analysis was performed on coded material. The
study was continued until 100 questionnaires had been re-
turned for each of the groups.
Return rates were 69%, 78%, 79%, and 67% in the pIBS,
sIBS, tIBS, and IBD groups, respectively.
Each questionnaire sought demographic information (age,
sex, marital status, race, educational status, employment status
in relation to their disease, occupation, father’s occupation,
and, thus, social class), as well as details about the duration of
illness, symptoms, global severity of symptoms, interference
with life, and adequacy of treatment. Severity of symptoms
(very mild to very severe), interference with life (not at all to
completely), and adequacy of treatment (poor to excellent)
were all rated on a 5-point scale. Patients also were asked
whether they had very seriously contemplated suicide or at-
tempted suicide specifically because of their gastrointestinal
illness as opposed to any other reason. The hospital anxiety
with a score greater than 10 for either parameter considered
indicative of significant psychopathology. We obtained ap-
proval for the study from the local ethics committee and all
patients gave written informed consent.
Statistical Analysis
Comparisons between the IBS and IBD groups were
performed using 1-factor analysis of variance together with
Scheffe’s multiple comparison test, the Kruskal–Wallis test,
and the ␹2 test as appropriate with Bonferroni corrections.
Stepwise changes in symptom severity, interference with life,
and inadequacy of treatment were assessed using a ␹2 test for
linear trend. Multiple logistic regression analysis was under-
taken to determine which factors were significant independent
predictors of suicidal ideation for the IBS patients. In this
analysis, symptom severity, interference with life, and ade-
quacy of treatment all were treated as simple dichotomous
variables comparing the 2 worst scores (4 and 5) with the
remaining 3.
Results
All patient groups were comparable in terms of
their demography with the exception of age and unem-
ployment caused by their disease. With regard to unem-
ployment, there was a stepwise increase in this parameter
in the IBS patients, with values of 0%, 13%, and 25%
for the pIBS, sIBS, and tIBS groups, respectively (P ⬍
.001). The value for the IBD group was 17%. With
respect to age, the pIBS patients were slightly younger
than the other groups, but adjusting all the comparisons
for age made no difference to the significance of the
results. Table 1 contrasts the data for the IBD and the 3
IBS patient groups and also shows the analysis of variance
results with relevant P values. When the tIBS patients
are used as the index comparator group, an asterisk
indicates significant differences between this and any
1066 MILLER ET AL CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 2, No. 12

other group for a particular parameter. As can be seen, Table 3. Results of Multiple Logistic Regression Analysis
38% of tIBS patients compared with 16% and 4% of Odds ratio (95% P value
sIBS and pIBS patients, respectively, had contemplated Factors confidence interval) (significance)
suicide specifically because of their gastrointestinal prob- Age .99 (0.96–1.02) .387
lem. The difference between each of these IBS groups is Sex .88 (0.31–2.54) .815
significant (tIBS vs. sIBS vs. pIBS, P ⫽ .002, P ⬍ .001). Symptom severity 3.37 (1.30–8.79) .013
HAD anxiety 1.12 (1.01–1.25) .036
It also is clear that there is a stepwise increase in the level HAD depression 1.16 (1.03–1.29) .011
of severity of symptoms, interference with life, and in- IBS category .006
adequacy of treatment from primary care through ter- Secondary vs. primary 2.21 (0.61–8.04) .230
tiary care patients, which is significant when analyzed for Tertiary vs. primary 5.77 (1.66–20.10) .006

a linear trend (P ⬍ .001).

Table 1 also allows comparison between the tIBS
patients and the active IBD patients. It highlights the
significant and excessive suicidal ideation rate in the tIBS
patients over the IBD patients (38% vs. 15%, P ⬍ .001).
The attempted suicide rate was higher in the tIBS pa-
tients (5% vs. 1% for IBD), although this did not reach
significance. The IBD group consisted of 56 patients
with Crohn’s disease and 44 patients with ulcerative
colitis, with a suicidal ideation rate of 16.1% in the
former and 13.6% in the latter group. Table 1 also
emphasizes the low degree of satisfaction with treatment
in the sIBS and tIBS groups compared with IBD patients
who were far more satisfied with therapy.
As can be seen from Table 1, the sIBS and the IBD
patients were rather similar in terms of their anxiety and
depression scores. It is noteworthy that the depression
scores in the sIBS group as a whole (6.3) and in the sIBS
patients contemplating suicide (9.7) did not exceed 10,
which is regarded as the upper limit of the normal range.
Even in the tIBS group as a whole, depression scores (8.3)
did not exceed the normal range, although in those
contemplating suicide the scores (11.7) were above the
normal range.
Table 2 documents the prevalence of anxiety and
depression in IBD and the 3 IBS groups as determined by
a value of 10 or greater for each of these parameters. As
can be seen, in IBS, anxiety is more common than
depression.
Table 3 details the results of the multiple logistic
regression analysis. Symptom severity (P ⫽ .013), anxi-
ety (P ⫽ .036), and the IBS category (P ⫽ .006) were
independent predictors of suicidal ideation as well as
depression (P ⫽ .011). With respect to the IBS category,
both the tertiary and secondary care groups had an
increased risk for suicidal ideation compared with the
primary care group, but this was only significant for the
tertiary group. Depression accounted for 22% of the
variance in the regression analysis compared with 25%
for symptom severity, 27% for the IBS group, and 29%
for anxiety.
Discussion
This study clearly shows that tIBS patients have
an extraordinarily high rate of suicidal ideation, which is
far in excess of that observed in a comparable group of
patients suffering from active IBD. Even secondary care
IBS patients are troubled by this problem as much as
individuals with active IBD. Symptom severity and in-
terference with life as a result of the inadequacy of
treatment seem to be important factors leading to this
situation.
There is considerable debate about the relationship
between psychologic factors and IBS, with views tending
to polarize toward the condition being either psychologic
or physical in origin.15,16 It could be argued that the
worrying findings highlighted in this study might all be
caused by depression and certainly the results of the
regression analysis point to depression as being an im-
portant independent predictor. However, depression
scores were within the normal range for the sIBS patients
contemplating suicide and only just exceeded the thresh-
old for abnormality in the suicidal tIBS patients, sug-
gesting that other factors also might be contributing to
this situation. Furthermore, the regression analysis
showed that depression accounted for only 22% of the

Table 2. Prevalence of Anxiety and Depression (HAD ⱖ10) in Primary, Secondary, and Tertiary Care IBS, and IBD Patients
Tertiary care Primary care Secondary care Active
group (%) group (%) group (%) IBD (%)

Anxiety 54.5 34.3 52.0 39.2

Depression 37.4 3.0 24.0 18.6
Total anxiety, depression, or both 61.6 34.3 54.0 45.4
December 2004
variance in suicidal ideation. It is noteworthy that sui-
cidal ideation has been reported to be increased in pa-
tients with pulmonary disease17 and chronic abdominal
pain,18 and has been shown not necessarily to be associ-
ated with depression.
One of the other factors contributing to suicidal ide-
ation could be hopelessness associated with an illness
from which there is little prospect of recovery or respite.
In the context of other diseases, it has been suggested
that this emotion may be more predictive of suicide than
depression.6 This possibility is supported by the fact that
disease severity was also an independent predictor for
suicidal ideation and it could be argued that disease
severity, interference with life, and inadequacy of treat-
ment all could contribute to a sense of hopelessness.
Hopelessness frequently is associated with chronic
pain,12 which also is associated with an increased risk for
suicide.9,11,12
The suffering related to long-standing, nonmalignant
disease can result in the desire for life to end7,8 and this
may differ from the anguish associated with psychiatric
disease. Thus, in addition to the prescription of psycho-
active drugs, other approaches may be worth considering
when trying to help patients in this situation. IBS pa-
tients frequently comment that they find it very hard to
confide in anyone about their illness because of the
embarrassing nature of its symptoms. They consequently
feel very alone, especially because individuals with other
chronic conditions often appear to be given much more
sympathy. The presence in someone’s life of a person
prepared to listen to all his or her problems can have a
role in suicide prevention.6 Thus, it is possible that the
provision of an individual, such as a specialist nurse who
can spend time counseling the most distressed of these
IBS patients, might be an effective way of treating this
problem in departments seeing large numbers of more
severe cases. We certainly have evidence that our hyp-
notherapists19,20 fulfill such a role. By using the level of
suicidal ideation in IBS and IBD as a marker of distress,
we estimate, using published data on prevalence and
referral,1,2,3,21–23 that there are at the very least 5 times
as many IBS sufferers experiencing equivalent or worse
distress (culminating in suicidal ideation) than there are
IBD sufferers, highlighting the magnitude of the prob-
lem. It is also of interest to note that psychologic distress
is far more common in patients presenting to secondary
care with IBS than with other organic gastrointestinal
problems.24,25 In a cluster analysis of 107 patients with
refractory IBS, Guthrie et al.26 identified a subset of 15
patients with a high prevalence of psychiatric problems
and excessive consultation behavior. They reported that 3
IBS AND SUICIDE 1067
patients (20%) in this small subgroup expressed suicidal
ideation but it is not clear whether this was related to
their psychiatric or gastrointestinal disorder.
One of the limitations of this study was the restricted
amount of data collected relevant to understanding the
cause of the suicidal ideation or any associated psychiatric
comorbidity. This study was designed to assess whether
suicidal ideation was a potentially important problem in
patients with IBS and consequently the questionnaire
deliberately was kept relatively brief to ensure a good
return rate. Without knowing the size of the problem it
seemed inappropriate to collect extensive data on issues
such as family history of suicide, substance or alcohol
abuse, sexual or physical abuse, and somatization. Simi-
larly, rather than burden patients with an in-depth psy-
chiatric questionnaire and an exploration of hopelessness,
the hospital anxiety depression questionnaire was used as
a screening instrument. However, now that this new
facet of IBS has been identified, we feel more extensive
research on this subject is justified and the design of
future studies should be enhanced by the experience
reported here.
We believe that these results also need to be placed in
perspective. Thus, it would be unrealistic to suggest that
the suicidal ideation identified in these IBS patients
necessarily results in actual suicide.6 However, it is rea-
sonable to assume that it acts as a marker for the level of
hopelessness and despair felt by these individuals, which
also may be manifested in some patients by depression.
Whatever the reasons for our observations, they empha-
size the point that there needs to be a change in attitude
toward patients with IBS that, at least in secondary and
tertiary care, can be associated with suicidal ideation or
depression, which needs to be identified and treated to
avert the potentially fatal consequence of suicide.
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Address requests for reprints to: P. J. Whorwell, Department
of Medicine, Education and Research Centre, Wythenshawe
Hospital, Manchester M23 9LT, United Kingdom. e-mail:
peter.whorwell@smuht.nwest.nhs.uk; fax: (0161) 291-5806 .
The authors are grateful to Julie Morris, Senior Medical Statistician,
for help with the statistical analysis.