1. Alcohol Use and Suicidal Behavior in College Students Dorian A. Lamis, PhD Department of Psychiatry & Behavioral Sciences Emory University School of Medicine

2. Alcohol, Suicide in Students Alcohol use – ~75% alcohol use past year – ~40% drink > 4-5 drinks/occasion past month – 20% have alcohol-related Dx Suicidal behavior (SB) – 2 nd leading cause of death – 18% ever seriously considered suicide – 8% lifetime suicide attempt © Alcohol Medical Scholars Program2

3. Clinical Case – Jane (Initial Visit) Check-up visit with personal physician 19 yr. old female 3-4 drinks/3X week No suicidal ideation Some depressive symptoms Behind with schoolwork Missing classes weekly Interpersonal difficulties © Alcohol Medical Scholars Program3

4. Lecture Covers Definitions Alcohol use and SB relationship Clinical implications Prevention implications Treatment approaches © Alcohol Medical Scholars Program4

5. Lecture Covers Definitions Alcohol use and SB relationship Clinical implications Prevention implications Treatment approaches © Alcohol Medical Scholars Program5

6. Definition of Alcohol Use Standard drink = 10-12 g pure ethanol – Beer: 12 oz/355 ml – Wine: 4 oz/120 ml – Spirits: 1.5 oz/44 ml Heavy episodic (HED) – Blood Alcohol Level (BAC) – HED ≈ 0.08 BAC – 4/5 drinks ♀ / ♂ within 2 hr © Alcohol Medical Scholars Program6

7. Alcohol Use Disorder (AUD) – ↑ Amount/time spent drinking – ↑ Time obtain/use/recover – Failure to fulfill life obligations – Giving up important activities – Drinking despite social problems – Drinking despite health problems © Alcohol Medical Scholars Program7 – Desire/inability to ↓/stop – Craving – Hazardous use – Tolerance – Withdrawal

8. Definition of Suicidal Behavior Suicidal ideation (SI) – Thoughts of killing oneself Suicide attempt – Non-fatal outcome with intent to die Suicide death – Fatal outcome © Alcohol Medical Scholars Program8

9. Lecture Covers Definitions Alcohol use and SB relationship Clinical implications Prevention implications Treatment approaches © Alcohol Medical Scholars Program9

10. Alcohol Use and Suicidal Behavior AUDs and: – Suicidal ideation: ↑ 4 X vs. no AUD – Suicide attempts: ↑ 6 X vs. no AUD – Suicide deaths: ↑ 9 X vs. Gen. Pop HED (4+ ♀ /5+ ♂ ) and: – Suicidal ideation: ↑ 2 X HED vs. no HED – Suicide attempts: 17% HED vs. 7% no HED – Suicide deaths: ~20% decedents ≥0.08 BAC © Alcohol Medical Scholars Program10

11. Potential Pathway 1: Alcohol Use & SB Alcohol use → impulsive/aggressive behaviors Impulsive/aggressive behaviors → life strains – Negative life events – Interpersonal difficulties – Alcohol-related problems Life strains → depressive symptoms Depressive symptoms → SB © Alcohol Medical Scholars Program11 Lamis & Malone, 2012

12. Depression → hopelessness Hopelessness → lack of connections/purpose in life Lack of connections/purpose in life → alcohol use Alcohol use → SB © Alcohol Medical Scholars Program12 Potential Pathway 2: Alcohol Use & SB Lamis et al., 2016

13. Major depressions confer risk for SB Co-morbid alc use and/or AUD → additional risk Many other variables involved © Alcohol Medical Scholars Program13 Both Likely To Operate

14. Lecture Covers Definitions Alcohol use and SB relationship Clinical implications Prevention implications Treatment approaches © Alcohol Medical Scholars Program14

15. Clinical Implications Screening - 85% depressed/suicidal students not receiving help Variety of settings - Throughout the school - Students coming for emergency care - College counseling centers - Primary care providers - Fraternities/sororities - Within athletic programs © Alcohol Medical Scholars Program15

16. Screening Tool for Alcohol Alcohol Use Disorders Identification Test (AUDIT-C) Items on: - Frequency of any alcohol use - Typical number of drinks - Frequency of 6+ drinks Responses are summed Score > 3/5 ♀ / ♂ indicates at-risk drinking © Alcohol Medical Scholars Program16

17. Screening Tool for Suicide Risk Beck Scale for Suicide Ideation (BSSI; 19 items) 5 screening items, 14 items intensity of ideation Responses are summed Score of >2 on 5-item screener = high risk ↑ score on total scale = ↑ suicidal ideation © Alcohol Medical Scholars Program17

18. Lecture Covers Definitions Alcohol use and SB relationship Clinical implications Prevention implications Treatment approaches © Alcohol Medical Scholars Program18

19. Prevention Implications-1 Docs should know about suicide risk factors - ~45% suicides met w/ physician - ~20% met with mental health provider Docs: Alcohol OR suicide risk present - evaluate both - Screening: If one risk present, screen for other - Monitoring: How both change over time - Prevention: If neither there, how to prevent - Treatment: How to reduce/stop both behaviors © Alcohol Medical Scholars Program19

20. Prevention Implications-2 Ask about SB - Asking does not ↑ SI - High-risk pts: asking can ↓ SI/distress If SI is present, ask: - Frequency, intensity, duration - Plan/preparatory steps - Intent © Alcohol Medical Scholars Program20

21. Is EMERGENCY if: - Recent social stressors and/or loss of resources - Severe psychiatric symptoms - Hopeless - Has suicide plan - Has available lethal means to carry out plan If emergency must take to mental health worker or ED © Alcohol Medical Scholars Program21 Prevention Implications-3

22. Initial PCP Evaluation: Jane Revisited No SI (Beck suicide scale = 0) Drinks 3 times/week; 4 drinks/occas (AUDIT-C = 4) No evidence of AUD Mentions relationship problems Reports depressive symptoms © Alcohol Medical Scholars Program22

23. Jane: Follow-Up Visit Drinks ↑ and more often (AUDIT-C = 7) Failing two classes Boyfriend broke up with her Hopeless SI (Beck suicide screen = 3; total = 16) © Alcohol Medical Scholars Program23

24. Lecture Covers Definitions Alcohol use and SB relationship Clinical implications Prevention implications Treatment approaches © Alcohol Medical Scholars Program24

25. Motivational Interviewing (MI) Therapeutic relationship collaborative Focused on pts thoughts/feelings Practitioner guides talk Motivate pt to change unhealthy behaviors Build motivation and commitment to live Explore ambivalence about change Guide pt towards change © Alcohol Medical Scholars Program25

26. CBT for Suicide Prevention-1 Initial phase (weekly sessions 1-3) Education - Nature of SB - How alcohol ↑ depression/SI - Restricting lethal means Behavior chain analysis - Individual in environment - Step-by-step sequence of events→ SI © Alcohol Medical Scholars Program26

27. CBT for Suicide Prevention-2 Collaborative safety planning - Coping strategies - List sources of support if SI Reasons for living - Identify reasons for staying alive - Hope kit: Photos/trinkets © Alcohol Medical Scholars Program 27

28. Middle phase (weekly sessions 4-9) Skills modules - Behavioral activation – ↑ pleasurable activities - Mood monitoring – Track daily moods - Emotion regulation 1) Do something enjoyable 2) Become anxious by worrying © Alcohol Medical Scholars Program28 CBT for Suicide Prevention-3

29. Skills modules (cont.) - Cognitive restructuring 1) Identify irrational thoughts 2) Provide alternate thoughts - Assertiveness skills 1) Effectively express point of view 2) While respecting others’ rights/beliefs © Alcohol Medical Scholars Program29 CBT for Suicide Prevention-4

30. End phase (weekly sessions 10-12) Relapse prevention - Review of suicidal crisis & high risk scenarios - Debriefing and follow-up Continuation phase (6 biweekly sessions) - Review skills - Discuss reactions to treatment & termination © Alcohol Medical Scholars Program30 CBT for Suicide Prevention-5

31. Integrated CBT for ALC & SB - 1 Guided by social cognitive learning theory (SCLT) - SCLT: Learning of social behaviors and core beliefs → MH problems - Assessment of alcohol use and SB - MI to improve motivation and readiness to tx - Develop self confidence/esteem © Alcohol Medical Scholars Program31

32. Integrated CBT for ALC & SB - 2 - Decrease underlying maladaptive cog/beh - Improve communication skills - Enhance problem solving - Improve emotion regulation © Alcohol Medical Scholars Program32

33. Dialectical Behavior Therapy Skills to ↓ alcohol and SB 4 types of skills: ↑ ability to - Focus on here-and-now - Have positive interpersonal relations - Regulate emotions - Tolerate bad situations/negative emotions © Alcohol Medical Scholars Program33

34. Conclusions/Summary Alcohol use and SB co-occur ↑ Systematic screening needed Ongoing assessment of both behaviors Identify/address alcohol use – suicide risk link Address both behaviors = most effective © Alcohol Medical Scholars Program34