For many sufferers of chronic fatigue syndrome (CFS) — an illness defined by its telltale exhaustiveness as much as it is by our inability to track down its cause(s) — the daily struggle to stay active and maintain the simplest of routines can be overwhelming at times. According to a new study published Wednesday in The Lancet, that struggle may ultimately leave them at greater risk of suicide.

Analyzing the medical records of more than 2,000 CFS patients enrolled in the United Kingdom’s publicly funded National Health Service (NHS) from 2007 to 2013, the researchers attempted to figure out if they were more likely to prematurely die than the general population, as represented by a similarly matched control group. While there didn’t appear any difference in overall mortality, whether from all causes of death or cancer, between the two groups, there was a fourfold difference when it came to completed suicides, albeit one with plenty of caveats.

“We did not note increased all-cause mortality in people with chronic fatigue syndrome, but our findings show a substantial increase in mortality from suicide,” the authors wrote. “This highlights the need for clinicians to be aware of the increased risk of completed suicide and to assess suicidality adequately in patients with chronic fatigue syndrome.”

Here’s where the caveats start. Out of 2147 cases of CFS, there were 17 deaths and 5 suicides observed in the 7 years they looked at. Though it’s purportedly the largest study of mortality in CFS patients compared to the general population, 5 deaths is still a small sample size (the expected suicide toll in the control group was less than one). As the authors themselves note, had there been two less suicides among CFS patients, the difference between the groups wouldn’t be statistically significant.

There’s also the fact that CFS patients studied by the authors may not necessarily be a good representation of CFS patients elsewhere, given that their willingness to go through a wide range of examinations and tests in order to receive their diagnosis. Oftentimes, people who experience CFS are reluctant to visit doctors out of fear their ailment will be framed as a mental illness rather than one rooted in a physical cause — there’s really no way to tell whether including these silent sufferers would influence the overall trend in suicide risk.

To their credit, the authors acknowledge these gaps and more, while still noting the unlikeliness of their findings simply being chance. The takeaway then is to better understand why CFS patients might be at a greater risk. According to an accompanying editorial written by Nav Kapur and Roger Webb, both members of the Center for Suicide Prevention at the University of Manchester, there are several possible explanations.

“Previous findings have shown that suicide might be more likely if people have a personal contact with someone who has died by suicide. We cannot rule out a clustering effect in this study; some of the people who died by suicide might have known each other,” they wrote. “Perhaps the most plausible explanation though is the one the researchers have explored — depression is a risk factor for suicide in people with chronic fatigue syndrome just as it is in the general population.”

It seems likely then that ensuring CFS patients are able to receive mental health care without feeling as though their physical symptoms are being dismissed as “imaginary” may go a long way.

Source: Roberts E, Wessely S Chalder T, et al. Mortality of people with chronic fatigue syndrome: a retrospective cohort study in England and Wales from the South London and Maudsley NHS Foundation Trust Biomedical Research Centre (SLaM BRC) Clinical Record Interactive Search (CRIS) Register. The Lancet. 2016.