Suicidality & Substance Abuse Bruce Michael Cappo, Ph.D. Clinical Associates, P.A

Suicidality & Substance Abuse

Bruce Michael Cappo, Ph.D.

Clinical Associates, P.A.

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Quo Vadis

Intro StatisticsCausalitySubstance factorsRisk FactorsWhat we knowWhat to do

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The Three Hs:

HopelessnessHelplessnessHaplessness

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Hopelessness

Strongest predictor of suicideStronger even than depressionOnly people who have lost all hope kill

themselves. Do whatever you can to build hope - however small it may be. They want to have hope in the future.

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Helplessness

The person views him or herself as being absolutely unable to make any changes to the situation or to his/her life

This characteristic should signal a high risk situation for you.

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Haplessness

These people often have very sad lives25% have a family history of successful suicidal

behavior in a relativeHigher percentage who have histories of mental

illness, depression, abuse, divorces, frequent moves and periods of unemployment in their family

Often there are multiple problems at the same time which just become too overwhelming.

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Suicide is a tragic and potentially preventable public health problem

8th leading cause of death in the U.S.10.6 out of every 100,000 persons died by

suicide

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The total number of suicides was approximately 31,000, or 1.3 percent of all deaths.

Approximately 500,000 people receive emergency room treatment as a result of attempted suicide each year

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Substance Use and the Risk of Suicide Among Youths

Approximately 3 million youths were at risk for suicide during the past year

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Youths who reported past year alcohol or illicit drug use were more likely than youths who did not use these substances to be at risk for suicide

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Only 36 percent of youths at risk for suicide during the past year received mental health treatment or counseling

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Underestmated Numbers?

Authorities agree that many suicides are not reported, but the National Center for Health Statistics records between 25,000 and 30,000 self-inflicted deaths in the U.S. annually.

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Attempts vs Completions

For every death from suicide, experts estimate that eight other suicide attempts are made. Suicide is now the second leading cause of death among persons 15 to 24 years of age. It is increasingly a problem among adolescents and elderly people.

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Statistical Indicators of Risk

Previous suicide attemptsThe verbalizing of suicide threatsThe giving away of prized personal

possessionsThe collection and discussion of

information on suicide methods

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The expression of hopelessness, helplessness, and anger at oneself or the world

Themes of death or depression evident in conversation, written expressions, reading selections, or artwork

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Statements or suggestions that the speaker would not be missed if he or she were gone

Physical symptoms such as eating disturbances, sleeplessness or excessive sleeping, chronic headaches or stomachaches, menstrual irregularities, apathetic appearance

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Use or increased use of substancesLook for sudden changes in behavior that

are significant, last for a long time, and are apparent in all or most areas of his or her life (pervasive).

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Often occur prior to acts of self-harm

The scratching or marking of the body, or other self-destructive acts

Recent loss of a friend or a family member (or even a pet) through death or suicide; other losses (for example, loss of a parent resulting from divorce)

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Often occur prior to acts of self-harm

Acute personality changes, unusual withdrawal, aggressiveness, moodiness, or new involvement in high-risk activities.

Sudden dramatic decline or improvement in academic performance, chronic truancy, tardiness, or running away

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Who is at highest risk for suicide in the U.S.?

Common misperception that suicide rates are highest among the young

Elderly, particularly older white males have the highest rates

Among white males 65 and older, risk goes up with age

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Who is at highest risk for suicide in the U.S.?

White men 85 and older have a suicide rate that is six times the national rate

White males are more deliberate in their suicide intentions

They use more lethal methods (firearms) & don’t tell of their plans

Older persons are less likely to survive attempts because they are less likely to recuperate

"They [researchers] cite a wide range of potential suicide triggers, from loss of employment or loved ones, to aging and physical impairment. But, in almost all cases, they agree there is an underlying psychiatric illness-primarily depression, followed by alcoholism and substance abuse.""The Mystery of Suicide," Newsweek, April 18, 1994

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Causality

No cause-and-effect relationship between use of alcohol and/or other drugs and suicide has been established

Substances often identified as a contributing factor

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Possible Explanations

Drinking, use of other drugs, or both may reduce inhibitions and impair the judgment of someone contemplating suicide, making the act more likely

Use may also may aggravate other risk factors for suicide such as depression or other mental illness.

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Alcohol/other drug problem prevention in reducing suicides:

High rates of alcohol involvement have been found among suicide victims who use firearms.

Recent studies suggest that alcohol tends to be associated with impulsive rather than premeditated suicides

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Between 20 and 35 percent of suicide victims had a history of alcohol abuse or were drinking shortly before their suicides

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Nearly 24 percent of suicide victims had blood alcohol concentrations (BACs) of .10 or greater

Similarly, an analysis of 100,000 deaths in 1989 found positive BACs in 35 percent of suicide fatalities

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In one study of youthful suicide, drug and alcohol abuse was the most common characteristic of those who attempted suicide

Fully 70 percent of these young people frequently used alcohol and/or other drugs

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In 1989, the cost of providing health care for people who had attempted suicide was estimated at $116.4 million annually

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Prevention works, and preventing alcohol, tobacco, and other drug problems also can help prevent suicide.

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Does alcohol and other drug abuse increase the risk for suicide?

A number of recent national surveys have helped shed light on the relationship between alcohol and other drug use and suicidal behavior. A review of minimum-age drinking laws and suicides among youths age 18 to 20 found that lower minimum-age drinking laws was associated with higher youth suicide rates

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In a study of all non-traffic injury deaths associated with alcohol intoxication, over 20 percent were suicides.

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Lower minimum-age drinking laws are associated with higher youth suicide rates

For particular groups at risk, such as American Indians and Alaskan Natives, depression and alcohol use and abuse are the most common risk factors for completed suicide

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In a large study of adults who drink alcohol, suicidal ideation was more likely reported among persons with depression

Persons who had made a suicide attempt were more likely to have had a depressive disorder and many also had an alcohol and/or substance abuse disorder

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Other Risk Factors

Aggressive behavior doubled suicide risk among boysPanic attacks nearly tripled suicide risk for girlsBeing a teenage runaway nearly tripled suicide riskPerfectionism has also been linked to suicide in some

studiesSubstance abuse appears to be a particularly

important factor when kids who have suicidal thoughts go on to make suicide attempts

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Substance Abuse May Escalate Suicidal Ideas to Attempts in Teens

A study in the September issue of the Journal of the American Academy of Child and Adolescent Psychiatry provides important insights into the relationships between psychiatric disorders and adolescent suicide, suggesting that teens who abuse drugs or alcohol are more likely to progress from suicidal thoughts to suicide attempts

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The research assessed the links among suicidal ideas, suicide attempts, and adolescent psychiatric disorders in a random sample of nearly 1,300 children aged 9 to 17 years. Of these, 67 had had suicidal thoughts 42 had made suicide attempts.

Adjusted for age and gender

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suicide attempts were significantly more likely for youngsters with mood disorders (depression and bipolar disorder), anxiety disorders, and substance abuse or dependence issues.

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In order to find it you must look

Recognition and appropriate treatment of mental and substance abuse disorders also hold great suicide prevention value

Most elderly suicide victims --70 percent -- have visited their primary care physician in the month prior to their suicides

Recognition and treatment of substance abuse and depression in medical settings can help prevent suicide in older adults

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Risk factors among people who have completed suicide

For particular groups at risk, such as American Indians and Alaskan Natives, depression and alcohol use and abuse are the most common risk factors for completed suicide.

Substance use & abuse occurs more frequently among youth and adults, compared to older persons.

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Alcohol and substance abuse problems contribute to suicidal behavior

Persons who are dependent on substances often have a number of other risk factors for suicide.

In addition to being depressed, they are also more likely to have social and financial problems.

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Alcohol and substance abuse problems contribute to suicidal behavior

Substance use and abuse can be common among persons prone to be impulsive, and among persons who engage in many types of high risk behaviors that result in self-harm

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What are the most common methods of suicide?

Firearms For men and women60 percent of all suicidesNearly 80 percent of all firearm suicides

are committed by white males

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Common Methods

The second most common method for men is hanging

The second most common method for women is self-poisoning including drug overdose

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Common Methods

The presence of a firearm in the home has been found to be an independent, additional risk factor for suicide. Thus, when a family member or health care provider is faced with an individual at risk for suicide, they should make sure that firearms are removed from the home.

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Male - Female Differences

More than four times as many men as women die by suicide

Women attempt suicide more often during their lives than do men

Women report higher rates of depression.

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Why the Gender Differences?

Completed suicide is associated with aggressive behavior that is more common in men

Men and women use different suicide methods

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Why the Gender Differences?

Women in all countries are more likely to ingest poisons than men

In countries where the poisons are highly lethal and/or where treatment resources scarce, rescue is rare and hence female suicides outnumber males

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If someone tells you they are thinking about suicide

Take their distress seriouslyListen non-judgmentallyEvaluate & get them to appropriate

treatmentPeople consider suicide when they are

hopeless and unable to see alternative solutions to problems

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If someone tells you they are thinking about suicide

Suicidal behavior is also more likely to occur when people experience stressful events (major losses, incarceration)

If someone is in imminent danger of harming himself or herself, do not leave the person alone.

Limit access to firearms or other lethal means of committing suicide.

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Are African American youth at great risk for suicide?

Historically, African Americans have had much lower rates of suicides

Rising at a faster rate for African American male youth

Trend is for a decrease in suicide across all gender and racial groups

Increase in suicide by firearms for all young males ‘Victim precipitated homicide’ in Black Males?

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Is suicide related to impulsiveness?

The mental disorders with impulsiveness most linked to suicide include borderline personality disorder among young females, conduct disorder among young males and antisocial behavior in adult males, and alcohol and substance abuse among young and middle-aged males

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Is suicide related to impulsiveness?

Impulsiveness appears to have a lesser role in older adult suicides

ADHD is not a strong risk factor for suicideImpulsiveness has been linked with aggressive

and violent behaviorsImpulsiveness without aggression or violence

present has also been found to contribute to risk for suicide.

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What biological factors increase risk for suicide?

Depression and suicidal behavior can be linked to decreased serotonin

Low levels of a serotonin metabolite, 5-HIAA, have been detected in CSF in persons who have attempted suicide, as well as by postmortem studies of suicide victims

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Can the risk for suicide be inherited?

Growing evidence that familial and genetic factors contribute to the risk for suicidal behavior

Major psychiatric illnesses, including bipolar disorder, major depression, schizophrenia, alcoholism and substance abuse, and certain personality disorders, which run in families, increase the risk for suicidal behavior

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Can the risk for suicide be inherited?

This does not mean that suicidal behavior is inevitable for individuals with this family history

Such persons may be more vulnerable and should take steps to reduce their risk, such as getting evaluation and treatment at the first sign of mental illness.

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Does depression increase the risk for suicide?

The majority of people who have depression do not die by suicide

Major depression does increase suicide risk compared to people without depression

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The risk of death by suicide may be related to the severity of the depression

About 2% of persons ever treated for depression in an outpatient setting will die by suicide

Among those ever treated for depression in an inpatient hospital setting, the rate of death by suicide is twice as high (4%)

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Those treated for depression as inpatients following suicidal ideation or suicide attempts are about three times as likely to die by suicide (6%) as those who were only treated as outpatients

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Gender Differences

There are significant gender differences in lifetime risk of suicide in depression

7% of men with a lifetime history of depression will die by suicide

1% of women with a lifetime history of depression will die by suicide.

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”Suicide Contagion"

Exposure to suicide or suicidal behaviors within one's family, peer group, or through media reports of suicide

Can result in an increase in suicide and suicidal behaviors

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Contagion

Direct and indirect exposure to suicidal behavior has been shown to precede an increase in suicidal behavior in persons at risk for suicide, especially in adolescents and young adults.

The risk for suicide contagion as a result of media reporting can be minimized by factual and concise media reports of suicide

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Contagion

Reports of suicide should not be repetitive, as prolonged exposure can increase the likelihood of suicide contagion

Family members, friends, peers, and colleagues of the victim should be monitored and possibly evaluated by a mental health professional

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Do school-based suicide awareness programs prevent youth suicide?

Few programs have been evaluated to see if they workOf the programs that have been evaluated, none has

proven to be effectiveSome programs have had unintended negative effects

by making at-risk youth more distressed and less likely to seek help

These programs present suicide as an option and ‘normalize’ it

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Is it possible to predict suicide?

No definitive measure to predict suicide or suicidal behavior

Factors can identify individuals at higher risk for suicide

Very few persons with these risk factors will actually commit suicide

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Prediction

Risk factors include mental illness, substance abuse, previous suicide attempts, family history of suicide, history of being sexually abused, and impulsive or aggressive tendencies

Suicide is a relatively rare event and difficult to predict statistically

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What to do...

Promote overall mental health among school-aged children by reducing early risk factors for depression, substance abuse and aggression

Detect youth most likely to be suicidal by confidentially screening for depression, substance abuse, and suicidal ideation

If a youth reports any of these, further evaluation takes place by professionals, followed by referral for treatment as needed

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Treatment Strategies - Meds

AntidepressantsCyclic antidepressants including tricyclics. MAO inhibitors SSRIs

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Treatment Strategies - Therapy

Psychodynamic /Interpersonal Psychotherapy

Behavior Therapy Cognitive Behavior Therapy (CBT) Electroconvulsive Therapy (ECT)

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Attempted Suicides

No annual national data on attempted suicide are available; reliable scientific research, however, has found that:

There are an estimated 8-25 attempted suicides to one completion; the ratio is higher in women and youth and lower in men and the elderly

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Attempts

More women than men report a history of attempted suicide, with a gender ratio of 3:1

The strongest risk factors for attempted suicide in adults are depression, alcohol abuse, cocaine use, and separation or divorce

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Attempts

The strongest risk factors for attempted suicide in youth are depression, alcohol or other drug use disorder, and aggressive or disruptive behaviors

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Risk of Suicide Attempt

3% Overall 22% children with major depression 25 % in those with substance abuse or

dependence.with two or more disorders, the rate of suicidal

ideation was eight times higher than normal, rate of suicide attempts was 18 times higher

than normal.

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Findings

Substance abuse or dependence is specifically related to suicide attempts

Substance abuse appeared to play a key role in the transition from suicidal thoughts to actual suicide attempts.

Certain psychiatric symptoms raise the risk of suicide.

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Time for Your Questions

Documents

Suicidality & Substance Abuse Bruce Michael Cappo, Ph.D. Clinical Associates, P.A