Dying for a Drink or Drug: Suicide and Addiction

1
Dying for a Drink or Drug Suicide and Addiction

• Richard Ries MD
• rries_at_u.washington.edu
• Harborview Medical Center and the University of
  Washington
• Seattle, Washington

2
Some Facts about Suicide

• 30,000 die by suicide in USA each year
• More die by suicide than homicide (1.7 times
  more)
• Third leading cause of death in those 15-24
  .more than cancer, AIDS, heart, and lung disease
  combined
• Males die 4x more often, but females make more
  attempts
• 60 die by firearm
• 
  CDC web site

3
Facts about Suicide

• 500,000 ER visits for attempts in 1997
• Four times as many US citizens died by suicide
  during the Viet Nam War period than died as
  soldiers.
• Rates increase with age ( as do other causes of
  death)
• Often Drug/Alcohol related
• 
  CDC web site

4
Is Suicide Primarily Mental Health Territory

• Lifetime Suicide risk for Schizophrenic,
  Affective and Addiction Disorders
• Method review of 83 mortality studies
• Schizophrenia4
• Affective Disorders6
• Addiction Disorders...7
• Inskip HM
  Br J Psych 1998

5
Or is Suicide alsoAddictions Territory?

• Alcohol strongest predictor of completed suicide
  over 5-10 years after attempt, OR 5.18vs.
  demog or psych disorders ( Beck J Stud Alc 1989)
• 40-60 of completed suicides across USA/Europe
  are alcohol/drug affected (Editorial Dying for
  a Drink Brit Med J. 2001)
• Higher suicide rates (8) in 18 vs. 21yo legal
  drinking age states for those ages (Birckmayer
  J Am J Pub Health 1999)

6
Standardized suicide mortality rates in men and
women with mean annual alcohol consumption in
liters per capita. Russia 1965-99.
Suicide in Women
Suicide in Men
Alcohol Consumption
Men
Women
7
Mean annual consumption with BAC-positives and
BAC-negatives for 8 Russian Regions 1981-1990.
Alcohol consumption
Suicide Rates per 100,000
BAC Positive Suicides
BAC Negative Suicides
Alcohol Consumption
8
Methamphtamine Users (n 1016) LIFETIME SUICIDE
ATTEMPTS and BEHAVIOR PROBLEMS
Zweben, et al., 2004
9
Crisis. 200526(2)78-84. Preliminary findings
of noncompliance with psychotropic medication and
prevalence of methamphetamine intoxication
associated with suicide completion. Callor WB,
Petersen E, Gray D, Grey T, Lamoreaux T, Bennett
PJ. Department of Psychiatry, University of Utah,
Salt Lake City 84132, USA. OBJECTIVE A study
of medical examiner records from suicide
completers was designed to identify potential
precipitating factors in the decision to commit
suicide.. Along with treatment issues, alcohol
and methamphetamine were the most common
substances found in the blood and/or urine of
suicide completers. CONCLUSIONS Accurate
diagnosis of mental illness, and improved
compliance with psychotropic medications may play
a critical role in suicide prevention. The
prevalence of methamphetamine in suicide
completers is unexpectedly high and requires
further investigation.
10
Arch Suicide Res. 200610(2)177-90 Suicidal
ideation among American Indian youths. Yoder
KA, Whitbeck LB, Hoyt DR, LaFromboise T.
yoder_at_pacs.unt.edu This study examined
correlates of suicidal ideation among 212
American Indian youth who lived on or near three
reservations in the upper Midwestern United
States. The youths were, on average, 12 years
old, and 9.5 reported current thoughts about
killing themselves. Females were over 2 times
more likely than males to think about suicide.
Multivariate logistic regression results
indicated that gender, enculturation, negative
life events, perceived discrimination,
self-esteem, and drug use were related to the
likelihood of thinking about suicide. Drug use
was the strongest correlate of suicidal ideation,
and both enculturation and perceived
discrimination emerged as important culturally
specific variables. It was suggested that
suicide prevention programs should draw on the
strengths of American Indian culture
11
Trauma Violence Abuse. 2006 Jan7(1)19-33.
American Indians and suicide a neglected area
of research. Olson LM, Wahab S. Department of
Pediatrics, University of Utah, USA. Suicide is
a major public health problem for American
Indians in the United States. Published studies
indicate that American Indians experience the
highest rate of suicide of all ethnic groups in
the United States. It is the second leading
cause of death in Indian young adults 1.5 x rate
of Non Indians over all 2.5 X rate or Non Indian
age 15-24 Alcohol, Drugs, Firearms usually
involved
12
Can addiction treatment affect suicidality?

• Cohort suicide attempts
• 
  year prior year after
• Adults
• gt 25 yo (n3524) 23........................
  ...4
• 18-24 yo (N651)
  28...........................4
• Adoles (n236)
  23...........................7
• Karageorge National Treatment Improvement
  Evaluation study 2001

13
Drug Alcohol Depend. 2004 Dec 776 SupplS21-9.
Suicidal behavior, drug use and depressive
symptoms after detoxification a 2-year
prospective study. Wines JD Jr, Saitz et al .
METHODS We examined factors associated with
drug-related suicidal behavior using
multivariable regression analyses in a 2-year
prospective study of 470 inpatients enrolled from
an unlocked, detoxification unit. Suicidal
behavior included suicidal ideation (SI) and
suicide attempt (SA). RESULTS
Baseline prevalence for SI was 28.5, and for
SA, 21.9. 2-year follow-up,
SI 19.9 for SA
6.9 Factors associated with suicidal behavior
at follow-up included past suicidal behavior,
more depressive symptoms, and more frequent
benzodiazepine and alcohol use. Cocaine and
heroin use did not reach statistical
significance.
14
1 J Stud Alcohol. 2004 Sep65(5)643-50.
Outcomes of substance use disorder treatment in
suicidal and nonsuicidal male patients. Ilgen
MA, Tiet Q, Moos R. METHOD A total of 2099
male SUD patients were recruited from 15
Department of Veterans Affairs residential
alcohol and drug treatment programs RESULTS
Although patients with a recent suicide attempt
reported severe patterns of alcohol use and
elevated psychiatric symptoms at baseline,they
showed significant improvements in both of these
domains at discharge from residential treatment,
and these improvements were still evident at
1-year and 5-year follow-ups.. Suicidal SUD
patients were no more likely to leave treatment
early than were nonsuicidal patients, and they
received slightly longer and more individualized
treatment. These findings imply that suicidal
SUD patients can be treated effectively within
SUD treatment settings.
15
Alcohol consumption, Alcoholics Anonymous
membership, and suicide mortalityrates, Ontario,
1968-1991.Mann RE, Zalcman RF, Smart RG, Rush
BR, Suurvali H. Method We studied the
impact of alcohol consumption levels, AA
membershiprates, and unemployment rates on
suicide mortality rates in Ontario from 1968
to1991. Results Total alcohol consumption
and consumption of each of beer, distilled
spirits, and wine were significantly and
positively related to total and female suicide
mortality rates. AA membership rates were
negatively related to total and female suicide
rates. Although data for males did not reach
significance (except for the relationship between
wine consumption and suicide rate), the direction
of effects was consistent with that observed for
female and total suicide rates.. (J. Stud.
Alcohol 67 445-453, 2006).
16
SoHow do you ask about suicide?How do you
assess danger?What do you do with suicidal
answers?
17
The following material is from the QPR Institute

• www.qprinstitute.com
• Courtesy of Dr Paul Quinnett
• Dr Ries is on the QPR board of advisors
• This model is included in the new
• Co-occurring TIP 42

18
Suicide Intervention Readiness

• Prepare yourself BEFORE a suicidal emergency
• What resources are available?
• How prepared are you, as an individual?
• Beginner/ Intermediate /Expert
• How prepared is your agency or group
• Beginner/ Intermediate/ Expert
• Is there a local Expert/Consultantwho?Phone
  etc

19
Preparation

• How prepared is your tribe/county
• Beginner/ Intermediate/Expert
• Who is your primary referral source for acute
  suicidal emergencies
• Phone , name of referral persons, what are the
  steps for referral etc
• Transportation method, records etc
• Rehearse all of the above

20
Trauma Violence Abuse. 2006 Jan7(1)19-33.
American Indians and suicide a neglected area
of research. Olson LM, Wahab S. Department of
Pediatrics, University of Utah, USA. Suicide is
a major public health problem for American
Indians in the United States. Published studies
indicate that American Indians experience the
highest rate of suicide of all ethnic groups in
the United States. It is the second leading
cause of death in Indian young adults 1.5 x rate
of Non Indians over all 2.5 X rate or Non Indian
age 15-24 Alcohol, Drugs, Firearms usually
involved
21
Interviewing Tips

• Never suggest their method wont work
• Never tell them how to do it better
• Never promise something you cant deliver unless
  it will save a life
• Skip the bumper sticker advise if the easy stuff
  worked you wouldnt be talking to them
• Dont start therapy
• Pay perfect attention
• Listen for lethality

22
A Good S Question

• - Have you been unhappy lately?
• Response, Yes.
• - Have you been very unhappy lately?
• Response, Yes.
• -Have you been so unhappy that youve wished you
  were dead?
• Response, Yes
• Has it been so bad you have thought of suicide?

23
More S Questions

• Do you wish you could go to sleep and never wake
  up?
• Are you planning to kill yourself?
• Have you been thinking about suicide?
• Have you had recurrent thoughts of death or
  suicide?
• You sound miserable, do you want to die?

24
HOW NOT TO ASK THE S QUESTION
Youre not thinking about killing yourself are
you? Other examples?
25
QPR

• Q for Question the person about suicide
• P for Persuade the person to get help
• R for Referring the person to someone who can
  help
• Three things youve already done a million
  times

26
QUESTIONS TO ASSESS RISKWhat, Why, Who, When,
Where, Why Not

• What is wrong?
• Elicits the persons narrative explanation or
  story.
• Persons perspective
• Value in story telling/emotional release
• Dont but in, except to clarify or understand
• Your opinion doesnt count, or matter
• Definition of rapport Shut up and Listen

27
WHY NOW?

• Elicits the precipitating event or events
• Current crisis?
• Hopeless a long time
• Magnitude of change event doesnt matter
• No reserves left
• Hair trigger condition
• Final straw
• I just cant take it anymore.

28
Why Now Questions

• Things have been bad for a long time, whats
  happened recently?
• Whats changed so much that youre now thinking
  about suicide?
• Why now? Why are you thinking about killing
  yourself today?

29
WITH WHAT?

• Elicits methods of suicide under
  consideration
• Guns are by far the MOST lethal
• How? (name them)
• Access to means?
• More than one method?
• Degree of lethal planning?
• Backup plan?
• Hopeless, intoxicated, isolated, and with a
  loaded gun is a lethal combination

30
With What Sample Questions

• Have you thought about how you would kill
  yourself?
• Can you tell me the way in which youve
  considered ending your life?
• How would you kill yourself?
• How else might you kill yourself?
• What method of suicide are you thinking about?

31
Where and When?Elicits possible location and
timing of a suicide attempt

• Lethal planning (less is good)
• Soon? Next week? Next year?
• Anniversary date? (Why that day?)
• Uncontrolled contingency, e.g., If she leaves.
• Home? Work? MVA?
• Chance of rescue?

32
What if a Gun is available

• Negotiate with the suicidal person to stay away
  from guns.
• Negotiate with family members to Remove them.
• Negotiate with friends or other support for
  Removal and storage.
• Involve Tribal Leaders
• Involve Tribal Police

33
When and With What in the Past?Elicits important
suicide history

• Past attempts?
• Past suicidal ideation?
• Rescue sought or avoided?
• Timing of attempt?
• Social response to attempt?
• What saved them?
• New method vs. old method?

34
Sample Questions

• Pat, youve been struggling with a lot of
  different problems lately and tell me youve been
  considering suicide. Have you ever had thoughts
  of suicide in the past?
• If yes then, When was that?
• How did you attempt to kill yourself?
• What method did you try?
• What helped you get through that crisis?

35
Whos involved?Elicits social psychological
context

• It usually takes two
• Who wont/cant help?
• Who can make it worse?
• Who cares and can make it better?
• Professionals involved?
• Double suicide pact?
• Murder-suicide?

36
Whos Involved Sample Questions

• Whos important to you?
• Who else knows youre in this much pain?
• Who is your main support?
• Who could help right now?
• Who needs to know about your troubles?
• Who have you told about your suicidal thinking?

37
Why Not Now?Elicits protective factors

• Reasons for living?
• Spiritual or religious prohibitions?
• Duties to others/pets?
• Tidying up or to list before dying?
• Fear of death?
• More reasons is good, none is bad
• Low risk does not equal no risk

38
Sample Why Not Now Questions

• Give me some reasons why you may want to live?
• Youve given me reasons why you want to die, can
  you tell me why you might still want to live?
• Give me three reasons to keep on going?

39
Warning Signs for Depression

• Two key Questions
• "Over the past two weeks, have you felt down,
  depressed or hopeless?"
• And,
• "Over the past two weeks, have you felt little
  interest or pleasure in doing things?" Yes to
  either question and a depression screening is in
  order
• Yes to either question will help identify 90 of
  untreated depressed persons U.S. Preventive
  Services Task Force

40
Depression and Stinkin Thinkin

• Also a cognitive illness characterized by
• - Slowed thinking
• - Tunnel vision (cognitive restriction)
• - Russian revisionism (recall only negative
  stuff)
• - Capacity to draw hasty, negative conclusions
• - Impaired problem solving
• - Poor logic, thus suicide makes sense
• - Inability to name reasons for living
• Stuck in the now of suffering
• Alcohol/Drugs can mimic depression and/ or make
  it worse.much worse

41
Additional Useful Questions

• Who else knows?
• Why in the past?
• Why not in the past?
• Who else in the past?
• What will happen after youre dead?
• How will people react?
• Who will find your body?

42
P Persuading Someone to Get Help

• Your active listening and questions may have
  already won the battle
• Find life-affirming solutions
• Refusal to seek help greater risk
• Angry hang up greater risk
• Unwillingness to give up means greater risk
• Help refused? Reassess risk
• Send in the Police/Fire, Mental Health
  professional, other Rescue?

43
R Referral

• Referral is an art and a sales job.
• Youre going to feel better, trust me.
• Resources ready?
• How to instructions matter!
• Can you personalize the endorsement?
• Culture/ethnic/profession/color sensitive?
• What sort of Tribal influence?
• Got a clinical buddy? Find one.

44
Safety Planning

• Suicide risk is determined, in large part, by the
  persons willingness to assume personal
  responsibility for his or her own safety.
• Despite a long list of current risk factors,
  overwhelming losses and a clear trigger event,
  most suicidal people will if they are not
  psychotic or so mentally ill they would be found
  eligible for involuntary hospitalization will
  agree to a life-saving safety and treatment plan.

45
Suicide risk is low to moderate when the person
agrees to

• Remain clean and sober
• Seek help/accept referral
• Remove the means of suicide
• Not harm or kill self
• Seek help in case situation worsens (involve
  others)
• Makes verbal agreement to safety plan

46
Suicide risk is high when the person

• Has not been cooperative. Not making sense?
  Psychotic? Agitated? Unable to care for self?
• Cannot regain emotional control, e.g., cant stop
  crying.
• Is distant, evasive, aloof or paranoid
• Is in the act of overdosing, has pistol in hand,
  is bleeding or calling from a 19th floor window
• Refuses to accept responsibility for self or
  safety plan, e.g., give up the means to suicide

47
Suicide risk is high when

• Past treatment has failed
• There is a risk of personal humiliation, e.g.,
  fear of pending arrest
• There has been recent heavy drinking
• There are repeated statements of hopelessness
• There is no perceived exit
• Youre ticked off
• Motto, Clark Faucett

48
Antidepressants and Addictions

• Numerous studies in Non-depressed show little/no
  benefit on substance use
• Several studies in mild/mod depressed show
  little/no benefit on substance use, no/mild
  effect on mood.
• Studies in Severely depressed/hospitalized show
  moderate positive effect on both mood and
  substance use
• McGrath et
  al Psych Clin N Am 01

49
Risk and Lethality

• Risk of Lethality
• Male 4/1 over females
• Guns 70
• Access
• Older gt70
• Alone/Loss of support
• Alcohol
• Serious illness
• Medical
• Psychiatric

• Risk of attempt
• Previous attempt
• Family History of Suicide
• Psychiatric disorder
• Alcohol/Drug disorder
• Alcohol/Drug Intoxication
• Loss
• Hopelessness/end of rope

50
Child Welfare. 2005 Mar-Apr84(2)323-36.
Rebuilding Native American communities. Coyhis
D, Simonelli R. White Bison, Inc., Colorado
Springs, CO, USA. The Wellbriety Movement in
Native American communities draws on the wisdom
and participation of traditional elders.
Beginning with a basic community teaching
called the Four Laws of Change and the Healing
Forest Model, the Wellbriety Movement blends
Medicine Wheel knowledge with the 12 Steps of
Alcoholics Anonymous to provide culture-specific
addiction recovery help for Native Americans.
The four Journeys of the Sacred Hoop brought
the Wellbriety Movement to Native and non-Native
people alike from 1999 to 2003.
51
Suicide Resources

• American Association of Suicidology
  www.suicidology.org
• American Foundation for Suicide Prevention
  www.afsp.org
• National Strategy for Suicide Prevention
  www.mentalhealth.org/suicideprevention/
• National Suicide Prevention Strategy
  www.sg.gov/library/calltoaction/

52
Suicide Resources

• Suicide Prevention Advocacy Network (SPAN)
  www.spanusa.org
• QPR institute www.qprinstitute.com
• Substance Abuse and Mental Health Services
  Administration www.samhsa.gov