addiction and suicide

1. Addiction and Suicide Rochelle Head-Dunham, MD FAPA Medical Director, LA Office for Addictive Disorders Clinical Assistant Professor of Psychiatry Tulane University school of Medicine rdunham@dhh.la.gov

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3. 3 Overview of Suicide Beck and Steer (1989) Alcoholism - strongest single predictor of subsequent completed suicide in a sample of attempted suicides Mino, Bousquet, & Broers (1999); Lester (2000) Drug users - high suicide mortality rate, (unclear extent to which it increases suicide rate in adults, or the role of specific drugs in completed suicides.)

4. 4 Overview of Suicide in Youth Suicide rates under age 30 increasing largely due to association with alcohol and drug use. Among adolescents and young adults suicide is: 3rd leading cause of death ages 15-24yrs 6th leading cause of death ages 5-14yrs >50% of teens who commit suicide have a history of alcohol and drug use

5. 5 Goals Address the prevalence and relevance of the co-morbid association between addiction and psychiatric disorders in suicidal populations Redefine addiction as a risk factor for suicidality Highlight implications for change in clinical practice.

6. 6 Suicide Defined Suicide (Latin suicidium, from sui caedere, to kill oneself) is the act of intentionally terminating one's own life; many dictionaries also note the metaphorical sense of "willful destruction of one's self-interest“ (Merriam-Webster, 2007). Suicide may occur for a number of reasons, often related to depression, shame, pain, financial difficulties or other undesirable situations.

7. 7 Suicide Defined Nearly a million people worldwide die by suicide annually (World Health Organization, 2006). There are an estimated 10 to 20 million attempted suicides every year (World Psychiatry, 2002). Elderly males have highest suicide rate, young adult rates increasing in recent years (World Health Organization, 2005) Nearly half of all suicides are preceded by an attempt at suicide that does not end in death. Attempters are 23 times likelier to eventually end their own lives than those without. (Bertolote JM et al, 2004) Difference in genders: Men More lethal, physical methods (guns…) Women More frequent, Less Lethal, less frightening (overdosing…) (National Center for Health Statistics. Deaths: Injuries, 2002)

8. 8 Suicide Defined Suicidal gestures Accidental killings underestimating the lethality of the method chosen overestimating the possibility of external intervention by others

9. 9 Suicide Defined The predominant view of modern medicine is that suicide is a Mental Health concern, associated with psychological factors such as the difficulty of coping with depression, inescapable suffering or fear, or other mental disorders and pressures. (World Health Organization, 2005)

10. 10 Suicide Re-Defined The pejorative view of addiction researchers is that suicide is an Addiction Concern associated with psychological factors such as the difficulty of coping with depression, inescapable suffering or fear, or other mental disorders and pressures.

11. 11 Co-morbidity and Suicide

12. 12 DSM-IV Diagnosis High Risk for Suicide Axis I: Mood D/O’s, Anxiety D/O’s Substance-induced D/O’s (mood and anxiety) Alcohol, Cocaine, Opiate, Marijuana, Sedative- Hypnotic Withdrawal/Intoxication and Abuse/Dependence Compulsive Gambling Disorder Axis II: Antisocial and Borderline Personality D/O’s Axis III: Chronic Medical Conditions (Hepatitis, Pancreatitis Peptic ulcers, pain syndromes, HIV, Cancer) Axis IV: High Psychosocial Stress (Employment, Academic, Relational…) (Diagnostic and Statistical Manual, 4th ed., 1994)

13. 13 Co-morbidity and Suicide (Roy, Lamparski, DeJong, Moore, & Linnoila, 1990) Alcoholic suicide attempters have been found to have: more comorbid diagnoses than nonattempters (e.g., multiple drug use, depression,antisocial characteristics), a poorer prognosis

14. 14 Suicide Attempts, Substance Abuse, and Personality (O’Boyle, M et al 1998) Suicide attempt histories among 103 subjects who had entered a substance abuse program and participated in a study of personality were examined. Findings: Twenty subjects had a positive suicide attempt history. Women were more likely to attempt suicide. Attempters were more likely to have additional psychiatric diagnoses, such as major depression. Attempters had higher addiction severity scores, abused more substances, and were more likely to have abused alcohol and sedative hypnotics than were non-attempters. Attempters had significantly higher neuroticism and borderline scores. Impulse dysregulation may predispose this group to more severe addictions.

15. 15 Office of Applied Studies(OAS) The Office of Applied Studies (OAS) Division of the Substance Abuse and Mental Health Services Administration (SAMHSA) Mission - collect, analyze, and disseminate critical public health data manages two national surveys: National Survey on Drug Use and Health (NSDUH) and Drug Abuse Warning Network (DAWN). Both Surveys offer insight into suicidal ideation and attempts and, in particular, drug-related suicide attempts

16. 16 2006 OAS Report Among adults aged 18 or older who experienced a past year major depressive episode (MDE), 56.3 % thought, during their worst or most recent episode, that it would be better if they were dead, 40.3 % thought about committing suicide, 14.5 % made a suicide plan, and 10.4 % made a suicide attempt

17. 17 2006 OAS Report Adults with a past year MDE who reported past month binge alcohol or illicit drug use were more likely to report suicidal thoughts and suicide attempts than their counterparts with a past year MDE who had not engaged in past month binge drinking or illicit drug use

18. 18 2006 OAS Report In 2004, an estimated 106,079 emergency department (ED) visits were the result of drug-related suicide attempts by persons aged 18 or older ? A psychiatric condition was diagnosed in 41 % (43,176) of the drug-related suicide attempts treated in the ED; the most frequent psychiatric diagnosis was depression

19. 19 Addiction: Independent Risk Factor for Suicide?

20. 20 Addiction as Risk Factor… Beck and Steer (1989) found: strongest predictor of eventual suicide in the 5–10 years after discharge from an acute psychiatric admission for suicide attempt was ongoing alcohol dependence, not demography or psychiatric diagnosis. Alcoholism has been associated with an increased risk of suicide attempts, ranging from 17% (Schuckit, 1986) to 29% (Whitters, Cadoret, & Widmer, 1985).

21. 21 Addiction as Risk Factor… Substance abuse has long been identified as risk factor for suicidal behavior. (Murphy, 1988) Specifically: Long-Term Use makes suicide more likely Nearly all alcoholic suicides occur among active drinkers Individuals often drink alcohol immediately before the suicide An alcoholic who remains abstinent has a lower risk of suicide

22. 22 Addiction as Risk Factor… The lifetime risk of completed suicide: For alcohol and drugs (7%) For mood disorders (6%) For schizophrenia (4%). (Inskip, Harris, & Barraclough, 1998)

23. 23 Substance-Induced Mood Disorder Substance-induced depression: can dissipate rapidly is as dangerous or more dangerous than major depressive disorder for risk of suicide and self-injurious behavior Asnis et al (1993) and Murphy and Wetzel (1990) alcohol dysregulates mood independent of use patterns some individuals are at risk of severe depression regardless of the chronicity of their alcohol use

24. 24 Substance-Induced Mood Disorder Elliot and colleagues (1996) patients who made medically severe suicide attempts had a statistically higher rate of substance-induced mood disorder than did patients who made less severe suicide attempts Most patients with substance-induced mood disorder did not meet criteria for substance dependence

25. 25 Substance-Induced Syndrome (SIS) Ries, RK et al, 2008 Examined the degree of substance-induced syndrome (SIS) in 5,116 acutely hospitalized suicidal psychiatric inpatients. Results: Identified a subgroup of the co-occurring population which was, More likely to be homeless, unemployed, uncooperative, Shorter lengths of stay with a more rapid improvement in symptoms. A high degree of addiction severity with temporary substance-induced suicidal syndromes (proximal vs distal use) High utilization of the most expensive level of care in the mental health system.

26. 26 Substance-Induced Syndrome (SIS) Ries, RK et al, 2008 (con’d) Implications of these findings: Psychiatric inpatient services need to provide intensive addiction intervention treatment, and Outpatient addiction services need improved capability and capacity to care for suicidal patients.

27. 27 Drug Use Data Harris & Barraclough, 1997 Heroin users, a 14-fold increase in rates of completed suicides Garlow, Purselle, & D’Orio, 2003 Patients with suicidal ideation presenting to an ER for Psychiatric services: 43.7% cocaine use disorder 38% both cocaine and alcohol use 24.3% only an alcohol use disorder

28. 28 Drug Use Data Among those with cocaine use disorders, 31% reported previous suicide attempts, (Darke & Kaye, 2004). Prevalence of cocaine use is reported as 20% in completed suicides in New York City (Marzuk et al., 1992). Methamphetamine-dependent individuals are reported to have high rates of depression and suicidal ideation (Kalechstein et al., 2000; Zweben et al., 2004). In one study of suicide completers done in Utah, the prevalence of methamphetamine found by toxicology screens was 9% in youth and 8% in adults (Callor et al., 2005).

29. 29 Drug Use Data (US Centers for Disease Control, 2006) Of 7277 suicide cases reported by the system: 73% positive for at least one substance (74.4% alcohol, 48.4% cocaine, 45.5% heroin or prescription opioid analgesic, 38.8% amphetamines, and 29.5% marijuana Of positive results for poisoning and non-poisoning suicides, prescription opioids number one cause for intentional overdose deaths than non-opioids, 5Xs more often (39.8% vs 8.2%)

30. 30 Drug Use Data Marijuana (MJ) Several studies have linked youth MJ use to depression, suicidal thoughts and schizophrenia: Young people who use MJ weekly have double the risk of developing depression Teens age 12-17 who smoke MJ weekly are 3xs more likely to have suicidal thoughts than non users MJ use in some teens has been linked to increased risk for schizophrenia in later years (Office of National Drug Control Policy/ONDCP, 2005)

31. 31 Drug Use Data Polysubstance use and intravenous (IV) drug use implicated as predictors of a higher prevalence of suicidal behavior as compared to non-IV drug or alcohol use disorders. (Havens, Sherman, Sapun, & Strathdee, 2006; Wilcox, Conner, & Caine, 2004) The U.S. National Comorbidity Survey data concludes, the number of substances used is more important than the type in predicting suicidal behavior. (Borges,Walters, and Kessler, 2000)

32. 32 Risk Factors

33. 33 Risk Factors for Attempted Suicide Substance Abusers have five times greater frequency of suicide attempts than non-abusers Alcoholics’ attempts 50% more common than non-alcoholics because of major depression Alcohol and cocaine use often to decrease depression but can actually increase anxiety depression and thoughts of suicide

34. 34 Risk Factors for Attempted Suicide Adults: Depression, alcohol abuse/active use, cocaine use, and interpersonal loss (separation and divorce), prior attempt. Youth: Depression, alcohol or other drug use disorder (including binge drinking and substance abuse), interpersonal problems/loss (parents' divorce, family violence, a breakup with a boyfriend or girlfriend, stress to perform and achieve, and school failure) and aggression or disruptive behaviors, prior attempt. Substance Users Unemployment, living alone, and/or lacking the support of family and friends at the time of this final and most severe upset, legal, financial and medical problems, prior attempt. (Roy, 1992)

35. 35 Risk Factors for Completed Suicide Current drinking Major depression Suicidal thoughts Loss of support from family and friends Living alone Unemployment

36. 36 Implications for change Evaluation Prevention and Treatment planning Treatment

37. 37 Implications for change Prevention  Aggressive treatment of substance abuse problems as well as mental health problems (diagnosing with expectation, during acute intoxication and visits for treatment of psychiatric distress,) Identification of high risk groups such as depressed, acutely intoxicated, alcoholic substance abusers, with or without cocaine, opiate, or sedative hypnotic use.

38. 38 Implications for change Prevention  ID Substance abusers with active suicide plans or recent suicide attempts who may need hospitalization, detoxification, or rehabilitation designed to encourage abstinence from alcohol and drugs of abuse. Firearms should be removed from the homes of substance abusers who talk about suicide, especially adolescents and young adults.  Make sure that a person at risk of suicide finds treatment for mental health and substance use problems, as well as increase social support from family, friends, and health-care professionals to reduce the risk of suicide

39. 39 Implications for Change Screening and Assessment Three Components: Screening (Modified Mini) Addiction Severity Index (ASI) ASAM Dimensional Assessment Psychiatric Evaluation

40. 40 Modified Mini Screening tool Administration Best results after 2 weeks of abstinence 22 item questionnaire, 15minutes Non-diagnostic; “Gateway questions” measure distress in the following areas: Section A – Mood Disorders Section B – Anxiety Disorders Section C – Psychotic Disorders Scoring: < 7 (low likelihood of MI), 7-8 (mild likelihood of MI), >8 (high likelihood of MI)

41. 41 ASI Dimensional Risk Factors Dimension I: Alcohol and Drugs Dimension II: Medical Conditions Dimension III: Psychiatric Dimension IV: Legal Dimension V: Employment/Support Dimension VI: Family/Social

42. 42 ASAM Dimensional Risk Factors Dimension I: Acute Intoxication/Withdrawal Dimension II: Bio-Medical Conditions and Complications Dimension III: Cognitive, Behavioral, and Emotional Conditions Dimension IV: Readiness/Motivation Dimension V: Relapse, Continued Use, Continued Problem Dimension VI: Recovery Environment

43. 43 DSM Risk Factors for Suicide Axis I: Mood D/O’s, Anxiety D/O’s Substance-induced D/O’s (mood and anxiety) Alcohol, Cocaine, Opiate, Marijuana, Sedative- Hypnotic Withdrawal/Intoxication and Abuse/Dependence Compulsive Gambling Disorder Axis II: Antisocial and Borderline Personality D/O’s Axis III: Chronic Medical Conditions (Hepatitis, Pancreatitis Peptic ulcers, pain syndromes, HIV, Cancer) Axis IV: High Psychosocial Stress (Employment, Academic, Relational…)

44. 44 Implications for Change Treatment Planning Patient Placement Determinations Medication management Psychosocial Supports Recovery Support Services/Community Linkages

45. 45 Discussion and Questions