The mental and physical health impact of Cognitive Behavioural Therapy on chronic pain – a scoping review protocol

Introduction

Chronic pain affects people globally with cross-national variation in prevalence, associated disability and reduced quality of life (Zimmer et al., 2022). Beyond its physical burden, chronic pain has profound psychosocial consequences, including elevated risks of depression, anxiety disorders, hopelessness, and in severe cases, self-harm and suicidality (Tang & Crane, 2006; Calati et al., 2015; Racine, 2018). Evidence also suggests that suicide risk may vary across different chronic pain conditions. Individuals living with conditions such as migraine, fibromyalgia, and neuropathic pain have been shown to higher rates of suicide outcomes as compared to pain free populations (Ilgen et al., 2008; Ratcliffe et al., 2008; Campbell et al., 2015).

Breivik et al. reported that patients with chronic pain have a fourfold higher risk of suicide attempt compared to the general population (Breivik et al., 2014). Similarly, a recent meta-analysis estimated a lifetime prevalence of suicidal ideation at 28.9% and suicide attempts at 10.8% among individuals with chronic pain, with more than one in four reporting suicidal ideations in the preceding two weeks (Kwon & Lee, 2023). Population based research has also shown chronic pain diagnoses to be nearly three times more common among suicide deaths, often alongside psychiatric comorbidities, highlighting the complex vulnerability of this group (DiBlasi et al., 2024).

Despite extensive evidence establishing chronic pain as an independent risk factor for suicide, this association remains poorly integrated into clinical risk prediction frameworks. This gap is further reflected in the design of clinical trials in chronic pain populations. Although outcomes such as pain intensity, disability, depression and anxiety are frequently assessed, suicide risk and suicidality outcomes are rarely included as primary or secondary endpoints. This highlights the disconnect between a known risk factor and its systematic absence in research practice (Forden et al., 2024; Mendes Neto et al., 2025).

While many studies have reported an association between chronic pain and elevated risk of suicidality, it is important to note that not all individuals experiencing persistent pain attempt suicide or engage in self-harm. This variability highlights the complex mechanism with interplay of neurobiological, cognitive, and psychological pathways that may contribute to suicide and self-harm risk in this population (Wiech & Tracey, 2009; Elman et al., 2013). Beyond depression and anxiety disorders, emerging evidence suggests that cognitive, emotional and psychological processes may be central to understanding why some individuals living with chronic pain are at greater risk than others (Kirtley et al., 2020; Themelis et al., 2025).

Chronic pain has been identified across multiple studies as a robust and direct driver of suicidality, mediating its effects both directly as a physical health burden and also through psychological mechanisms to give rise to pain catastrophizing, feelings of hopelessness, entrapment, perceived burdensomeness, loss of meaning in life, social isolation and reduced self-efficacy each of which are recognized as predisposing factors for suicidal thoughts and behaviors (Edwards et al., 2006; Tang et al., 2007; O’Connor, 2011; Racine, 2018; Klonsky et al., 2021). Yet these pathways have rarely been measured together in a structured and systematic way within pain research. Hence, it remains difficult to determine which specific mental and physical health outcomes of the chronic pain experience drive suicide risk, whether independently or in combination. Mapping these outcomes would identify mediating and moderating factors, distinguish subgroups of patients at elevated risk, and test theoretically grounded models of suicidality such as the Interpersonal Theory of Suicide, in which chronic pain may directly amplify both thwarted belongingness and perceived burdensomeness.

Despite increasing recognition of these individual factors, the extent to which these comorbid physical and mental health outcomes independently contribute to, or interact with, psychological mechanistic factors to elevate suicidality in chronic pain populations remains poorly understood. Consequently, this underscores the need for comprehensive understanding of these interconnected factors in chronic pain populations at risk of suicidality and self-harm.

Within chronic pain populations, this interplay also has important implications for diagnostic assessment and treatment. Although non-opioid analgesics such as paracetamol are among the most prescribed pain medications, evidence suggests that opioids, presents an additional concern in the context of suicidality. Opioids are consistently identified among the most employed agents in suicide attempts and deaths, leading to increased risk in individuals with chronic pain (Alothman et al., 2023). This reinforces the critical importance of integrating and prioritising non-pharmacological interventions, which not only address pain management but also reduce dependence on potentially lethal pharmacological agents.

Cognitive Behavioural Therapy (CBT) is well established in the treatment of mood disorders and chronic pain (Ehde et al., 2014; Williams et al., 2012). It offers structured, skills-based strategies and has demonstrated efficacy in reducing pain interference, pain related disability, and psychological distress (Buhrman et al., 2016; Sanabria-Mazo et al., 2023). Recent developments have expanded the scope of CBT intervention delivery. Emphasis is being made on the scalability and maintenance of treatment gains from psychological interventions for chronic pain, particularly with respect to long-term outcomes such as suicidality (Dorfman et al., 2025; Darnall, 2025).

While CBT reliably improves some psychological outcomes, its effects on suicidality in chronic pain population remains underexplored and inconsistently reported (Sanabria-Mazo et al., 2023). To improve the effectiveness of psychotherapeutic approaches for pain and its associated mental and physical health impacts, we need to better understand treatment mechanisms (Burns, 2016). Also, most research has focused on specific pain conditions or on comparative efficacy between CBT and alternative interventions (e.g., mindfulness or acceptance-based approaches), rather than systematically examining suicide-related psychological outcomes across chronic pain populations.

This scoping review aims to address this gap by systematically examining CBT’s effects on broader mental and physical health outcomes such as depression, hopelessness, pain intensity, sleep disturbances and quality of life in chronic pain populations. This review will additionally explore CBT interventions for chronic pain populations in which suicidality or self-harm is present or assessed. We will also search for evidence on how CBT influences suicide risk in chronic pain populations, via exploring mechanisms and characterizing delivery formats, study contexts, and knowledge gaps in the field. By addressing these gaps, this review will lay the groundwork for future trials that integrate suicide prevention within psychological pain management and inform the development of clinical guidelines in this area.

Methods

This scoping review will be developed and conducted in accordance with JBI guidance for the conduct of scoping reviews (Peters et al., 2022) and reported following the framework outlined by the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) (Tricco et al., 2018) guidelines to ensure transparency and rigor in the review process.

Conclusion

This scoping review addresses the growing recognition of chronic pain as a distinct clinical condition and its established association with increased risk of suicidality and self-harm. While CBT is widely used in the management of chronic pain, its role in addressing suicidal ideation and behaviours within this population remains unclear. In addition, limited attention has been paid to the underlying mechanisms through which CBT may influence both physical and mental health outcomes. By systematically mapping the existing evidence, this review will provide a comprehensive overview of the current literature, identify mechanisms and psychological processes linked to suicide risk, to inform future research directions, including the development of targeted interventions for individuals with chronic pain.