1. ©AMSP 20081 Suicidal Behavior, Alcohol, and Alcohol Use Disorders Timothy W. Lineberry, M.D. Assistant Professor, Psychiatry Mayo Clinic

2. ©AMSP 20082 US Prevalence Suicidal Behavior %/yr#/yr Thoughts3.39,900,000 Attempts 0.6 (4.6 Lifetime) 1,800,000 (13,800,000) Suicide~ 0.01>32,000

3. ©AMSP 20083 %/yr (Lifetime) #/yr (Lifetime) Hazardous2575,000,000 Abuse 5 (18) 15,000,000 (54,000,000) Dependence 4 (13) 12,000,000 (39,000,000) US Prevalence Alcohol Use Disorders

4. ©AMSP 20084 This Lecture will Cover Definitions Relationship Screening & identification Assessment & management

5. ©AMSP 20085 Hazardous Drinking Men  5 drinks/day or  15 drinks/week Women  4 drinks/day or  8 drinks/week “At risk” for  alcohol-related problems NOT alcohol abuse or dependence

6. ©AMSP 20086 Alcohol Abuse –12-month pattern of problems in  1 of: Inability to meet obligations Physically hazardous situations Legal problems Social or interpersonal problems –Not alcohol dependence

7. ©AMSP 20087 Alcohol Dependence 12-month pattern of problems in  3 of: –Tolerance:  use = same effect –Withdrawal: Use to relieve/avoid withdrawal –Use larger amounts/longer than intended –Desire to or unsuccessful efforts to cut down –  time spent in alcohol-related activities –Give up important social activities –Continued use despite persistent problems

8. ©AMSP 20088 Major Depressive Disorder (MDD) MDD lifetime prevalence: ♀ 15%: ♂ 8% Must represent change in function Subjective report or observation of others > 5 symptoms nearly daily for 2-weeks Must have at ≥ 1 of following 2 1. Depressed mood most of the day 2. ↓ interest/pleasure in most activities

9. ©AMSP 20089 Additional MDD Criteria Weight ↓ or ↑ or appetite ↓ or ↑ Sleep ↓ or ↑ Psychomotor agitation or retardation Fatigue or ↓ energy Feelings of worthlessness or inappropriate guilt ↓ Ability to think/concentrate or indecisiveness Recurrent SI or thoughts of death

10. ©AMSP 200810 Suicide-related Behavior Ideation = thoughts of Attempt = deliberate self-harm Completion = death from attempt

11. ©AMSP 200811 This Lecture will Cover Definitions Relationship Screening & identification Assessment & management

12. ©AMSP 200812 Alcohol Use Disorders and Suicide Alcohol use disorders Suicide ~25%

13. ©AMSP 200813 Alcohol Dependence and Suicide Suicidal ideation ↑ 3-5X Suicide attempts ↑ 4-6X Lifetime suicide rate 7-10%

14. ©AMSP 200814 Major Depression ~40% of suicides have MDD 20% with MDD attempt in lifetime Lifetime suicide rate varies with severity of depressive illness –Psych. hospitalized + SI: 9% –Hospitalized without SI: 4% –Outpt. depression: 2%

15. ©AMSP 200815 Depression and suicide Depression Suicide ~40%

16. ©AMSP 200816 Which came First? 80% of patients with alcohol dependence report lifetime depressive symptoms Sustained heavy alcohol use induces depressive symptoms

17. ©AMSP 200817 “Independent” MDD Predates alcohol dependence diagnosis or occurs in times of sustained abstinence More likely to have family history of MDD 15% of alc dependence patients

18. ©AMSP 200818 Alcohol Induced MDD Temporary sxs associated with use –Typically resolve in ~ 4 weeks Resolve with sustained abstinence Family history of MDD less likely 26% of alc dependence patients

19. ©AMSP 200819 Alcohol Dependence and MDD MDD Alcohol Dependence Alcohol Induced 26% Independent 15%

20. ©AMSP 200820 Depression + Alcohol Dependence  Suicide rate Independent depression ↑ suicide attempt rate vs. alcohol induced Increasing age  risk for both Depression and alcohol use disorder make up ~65% of all suicides

21. ©AMSP 200821 Major Depression Suicide- related behaviors Alcohol use disorders Alcohol Use Disorders are Related to Suicide

22. ©AMSP 200822 This Lecture will Cover Definitions Relationship Screening & identification Assessment & management

23. ©AMSP 200823 Ask Everyone! <25% patients routinely screened for alcohol use ~ 40% with MDD missed by primary MD 35% with known MDD asked about suicide MDs report discomfort with asking MDs miss obvious clinical patterns

24. ©AMSP 200824 Patients Expect To be asked about alcohol use To be asked about emotional problems Guidance about use and risky behaviors Judge MD skill based on their attention to

25. ©AMSP 200825 Evidence Based Screening Screening ≠ diagnosis Screening tools include – History – Survey – Physical exam – State markers (laboratory) + Screen requires full evaluation

26. ©AMSP 200826 CAGE Cut down, Annoyed, Guilt, Eye- opener Positive test > 2 yes answers Sensitivity → 50-80% Specificity → ~ 80% Doesn’t screen for hazardous drinking

27. ©AMSP 200827 AUDIT 10-item survey Developed by W.H.O. Score of > 8 = positive test for hazardous drinking/ ↑ chance of alc. dx Sensitivity → ~70% Specificity → 80% 3-item survey Sensitivity/specificity = to 10-item AUDIT Positive score –Men > 4 –Women ≥ 3 AUDIT-C

28. ©AMSP 200828 Physical Examination  3 drinks/day  risk of hypertension Hepatosplenomegaly (liver/spleen size  ) Peripheral neuropathy: 15% w/alc dep

29. ©AMSP 200829 State Markers Blood tests Change with heavy sustained alcohol use –Gamma-glutamyl transferase (GGT) –Carbohydrate Deficient Transferrin (CDT) –CBC w/Mean Corpuscular Volume (MCV) –Aspartate transaminase (AST)

30. ©AMSP 200830 2 Question Depression Screening In the past month… 1. Have you been bothered by feeling down, depressed, or hopeless? 2. Have you been bothered by little interest/pleasure in doing things? ≥ 1 yes = positive test Sensitivity: 96%; specificity: 57% Remember! screening ≠ diagnosis

31. ©AMSP 200831 This Lecture will Cover Definitions Relationship Screening & identification Assessment & management

32. ©AMSP 200832 Manage At Risk Patients  Positive screen  History, survey, physical exam, state markers  Full evaluation  Use diagnostic criteria  Evidence-based treatments

33. ©AMSP 200833 Define MDD in Alcohol Use Timeline interview Carefully assess lifetime MDD sxs Sxs present w/sustained abstinence? Family history of depression?

34. ©AMSP 200834 Evidence Based Treatments Motivational Interviewing Cognitive Behavioral Therapy Disulfiram Naltrexone Acamprosate

35. ©AMSP 200835 SAFE-T Suicide Risk Assessment Risk factors Protective factors Suicide inquiry Assess risk & level of care Document

36. ©AMSP 200836  Intent  Plan  Suicidal ideation  Thoughts of death  Hopelessness Stepwise assessment ©AMSP 2008 41

37. ©AMSP 200837 Assess Risk and Level of Care Clinical judgment Low risk → outpt follow-up Moderate → psychiatry/ER High → hospitalization

38. ©AMSP 200838 Summary Definitions Relationship Screening & identification Assessment & management