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Suicide Risk and C0-Occuring Disorders SCDMH Medical Directors Skill Maintainence Initiative 11-16-2011 Robert Breen MD Medical Director Bryan Psychiatric.

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Presentation on theme: "Suicide Risk and C0-Occuring Disorders SCDMH Medical Directors Skill Maintainence Initiative 11-16-2011 Robert Breen MD Medical Director Bryan Psychiatric."— Presentation transcript:

1 Suicide Risk and C0-Occuring Disorders SCDMH Medical Directors Skill Maintainence Initiative Robert Breen MD Medical Director Bryan Psychiatric Hospital DIS-SCDMH

2 Suicide Risk and Co-Occuring Disorders 1. Examine how substance abuse affects suicide risk 2. Examine suicide risk in different components of the four quadrant model 3. Describe available suicide risk management options for persons needing substance abuse treatment

3 Suicide Rate in SC YearNumberRate SCVDRS and CDC

4 Jamison

5 How does Substance Abuse Interact with Suicide Risk Suicide Risk and Substance Abuse

6 Suicide Risk Compared with the general population, individuals treated for alcohol abuse or dependence are at about 10 times greater risk for suicide. People who inject drugs are at about 14 times greater risk for suicide (Wilcox, et al., 2004). Suicide Prevention Efforts for Individuals with Serious Mental Illness National Association of State Mental Health Program Directors Medical Directors Council March 2008

7 Suicide Risk and Substance Abuse

8 Alcohol and drugs can: –Deplete serotonin, dopamine and other neurotransmitters linked to suicide Suicide Risk and Substance Abuse

9 Drugs to overdose by: –Opiates –Cocaine –Benzodiazepines –Inhalants Suicide Risk and Substance Abuse

10 Suicide Risk Alcohols acute effects include disinhibition, intense focus on the current situation with little appreciation for consequences, and promoting depressed mood, all of which may increase risk for suicidal behavior (Hufford, 2001). Other central nervous system depressants may act similarly. Addressing Suicidal Thoughts And Behaviors in Substance Abuse Treatment SAMHSA TIP

11 Suicide Risk Depression is a common co- occurring diagnosis among people who abuse substances that confers risk for suicidal behavior Other mental disorders are also implicated. Addressing Suicidal Thoughts And Behaviors in Substance Abuse Treatment SAMHSA TIP

12 Suicide Risk Intense, short-lived depression is prevalent among treatment-seeking people who abuse cocaine, methamphetamines, and alcohol, among other groups (Brown et al., 1995; Cornelius, Salloum, Day, Thase, & Mann, 1996; Husband et al., 1996). Even transient depression is a potent risk factor for suicidal behavior among people with substance use disorders. Addressing Suicidal Thoughts And Behaviors in Substance Abuse Treatment SAMHSA TIP

13 Alcohol can increase suicide risk by: –Makes it easier to go ahead with an attempt –Makes attempts more lethal –Interferes with effective problem solving skills Suicide Risk and Substance Abuse

14 Characteristics of the Person with Alcohol Problems who Suicides Started drinking at young age Consumed alcohol over long period of time Drank heavily Poor physical health Depressed Disturbed and chaotic lives Recent interpersonal loss Performed poorly at work Family history of alcoholism Adapted from World Health Organization 2000

15 Studies in Denmark and the USSR demonstrated that suicide rates decreased with more restrictive alcohol policies While in the US increases in alcohol consumption correlate with increase in suicide rates Suicide Risk and Substance Abuse

16 Risk Clusters 1. Mental illness + Alcohol problems 2. Mental illness + recent Crisis 3. Mental illness only 4. Depression + Financial problems (little treatment) 5. Alcohol problems + Stressors (some depression) 6. Depression + MEDICAL PROBLEMS (little treatment) 7. Legal problems + recent Crisis (interpersonal problems) 8. Interpersonal problems + recent Crisis + Alcohol 9. Alcohol Intoxication at the time of death (dependence) Suicide Categories by Patterns of Known Risk Factors: A Latent Class Analysis Logan, Hall, Karch. Arch Gen Psychiatry 2011;68(9):

17 National Suicide Prevention Hotline Core Principles Suicide and Life-Threatening Behavior 37(3) June The American Association of Suicidology SUICIDE SUCIDE SUICIDAL BUFFERS/ SUICIDE SUCIDE SUICIDAL BUFFERS/ DESIRE CAPABILITY INTENT CONECTEDNESS DESIRE CAPABILITY INTENT CONECTEDNESS Ideation Attempt historyAttempt Immediate Supports Ideation Attempt historyAttempt Immediate Supports in progress Psychological Violence history Social supports pain pain Hopelessness Available means PlanPlanning for the future method known method known Perceived burden Intoxicated Engagement Feeling trapped Substance abusePreparatory Ambivalence behaviors Intolerably alone Psych symptoms Core values beliefs Agitation/rageExpressed Sense of purpose Agitation/rageExpressed Sense of purpose intent to die

18 The CTS Suicide Equation Desire X Intent X Capability Buffers

19 The Suicide Equation Pain X Hopelessness X CAPABILITY Connectedness

20 Suicide and Substance Abuse in South Carolina Suicide Risk and Substance Abuse

21 2003 Suicide in South Carolina Adolescent male with interpersonal problem, probable substance abuse but possibly not depressed and not treated Adult male with intimate partner problem, probable mental illness, possibly in treatment, possible substance abuse Elderly male with physical problems, depressed, but likely not acknowledging depression and not in treatment

22 2003 Suicide in South Carolina Age % Interpersonal problem 50% Interpersonal problem 38% Substance abuse problem 38% Substance abuse problem 25% Depressed mood 25% Depressed mood 25% Mental health problem 25% Mental health problem 12.5% Current mental health tx. 12.5% Current mental health tx. SC-DHEC- SCDVRS

23 2003 Suicide in South Carolina Age % Depressed mood 39.8% Mental health problem 37.8% Problem with partner 18.9% Alcohol problem 18.1% Physical health problem 37.4% Current mental health tx. SC-DHEC- SCDVRS

24 2003 Suicide in South Carolina Age 55-older 63.3% Physical health problem 62.6% Depressed mood 31.7% Mental health problem 18.1% Current mental health tx. SC-DHEC- SCDVRS

25 Suicide Risk In the Elderly ADDITIONAL RISK FACTORS FOR SUICIDE IN OLDER PERSONS Heavy alcohol use Presence of mental disorders in addition to depression Presence of a serious physical illness Social isolation, particularly after the death of a spouse or close friend Access to firearms JAMA Patient Page Vol. 291 No. 9, March 3, 2004

26 Suicide Risk in the South Carolina Public Sector Suicide Risk and Substance Abuse

27 Risk clusters from SCDMH reports Cluster 1 Cluster 1 White, male Mood disorder Lost wife or girl friend Lost income: Cannot keep a job Cannot keep a job Disability assistance turned down Disability assistance turned down Suffering from chronic pain Alcohol/ substance abuse Young adult male about to go to jail (again) Methods: Gunshot, Hanging

28 Risk clusters from SCDMH reports Cluster 2 Cluster 2 Schizophrenia (CUS) Male or female Occurs without warning With or without depression Methods: Struck by train Leaping in front of moving trucks/cars Leaping in front of moving trucks/cars Leaping from overpass onto roadway Leaping from overpass onto roadway

29 Risk clusters from SCDMH reports Cluster 3 Cluster 3Female Mood Disorder, especially Major Depression Substance abuse, addiction to Rx medications Personal Health Issues (e.g., cancer) Unresolved early-age trauma? Method: Overdose

30 Risk clusters from SCDMH reports Cluster 4 Cluster 4 Either sex, grieving over lost/dead friend or child Major Depression Alcohol is prominent coping mechanism Believes she/he can be reunited with the lost one in death (this may be a covert belief) Method: Gunshot, often near the grave of the lost one

31 Suicide Risk Suicide risk often goes undetected, even though individuals at heightened risk for suicide frequently seek and receive medical care in primary care settings. Screening of persons with depression and substance abuse in primary care settings can identify individuals at elevated risk for suicide and expedite their referral for definitive evaluation and treatment. Recommendation: The SMHA (DMH), in collaboration with the SHA, should require screening for suicide risk at all primary care appointments for those individuals who exhibit risk factors such as depression or substance abuse. Suicide Prevention Efforts for Individuals with Serious Mental Illness National Association of State Mental Health Program Directors Medical Directors Council March 2008

32 Suicide Risk Assessment Suicide Risk and Substance Abuse

33 Suicide Risk The risk for suicidal behavior may increase at any point in treatment Suicide risk may increase at transition points in care Suicide risk may increase when a clients treatment is terminated administratively In clients with a history of suicidal thoughts or attempts suicide risk may increase with relapse In clients with a history of suicidal thoughts or attempts suicide risk may increase when a client implies that the worst might happen if they relapse In clients with a history of suicidal thoughts or attempts suicide risk may increase when they are experiencing acute stressful life events Addressing Suicidal Thoughts And Behaviors in Substance Abuse Treatment SAMHSA TIP

34 Suicide Risk and Co-Occurring Disorders The Four Quadrant Model Addressing Suicidal Thoughts And Behaviors in Substance Abuse Treatment SAMHSA TIP

35 Suicide Risk Quadrant I folks should be low risk, as suicidal ideation with significant risk factors would raise the MI severity level

36 Suicide Risk Quadrants II and III would have elevated suicide risk and should be screened for suicide risk factors when life stressors/losses occur

37 Suicide Risk Quadrant IV folks would present significant risk and monitoring for changes in suicide risk should be an ongoing concern for case management and at psychiatric assessment.

38 Crisis Suicide Assessment Safety Plan Must be willing to engage in treatment! Get patients commitment to follow-up assessment! Must not have impulsive access to method! Must have responsible others to monitor for worsening who willingly collaborate on safety plan! Must agree to not use alcohol and/or street drugs! Ask about firearms!

39 The End Suicide Risk and Substance Abuse


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