Dying for a Drink or Drug: Suicide and Addiction

Richard Ries MDrries@u.washington.eduHarborview Medical Center and the University of WashingtonSeattle, Washington

Harborview Health Services Research GroupPeter Roy-Byrne MD chiefPrim care x psychRichard Ries MD.Addiction, Co-occurring,SuicideDoug Zatzick MDTrauma, PTSD Rx + PrevMark Snowden MD.GeropsychKate Comtois PhD..Suicide, Borderline PD, High UtilizersChris Dunn PhD......Motiv interventions AlcTraumaJoan Russo PhD..Data management, stats, DMHarborview Injury Prev Center

NEW Center for Vulnerable MH, Addictions, Medical Populations

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

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

Is Suicide Primarily: Mental Health TerritoryLifetime 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

Or is Suicide Addictions 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)

What do we know about Suicide in Alcoholic Populations4.5% of alcoholics attempted suicide within 5 years of DX ( age 40.. n=1,237)

0.8% in non-alcoholic matched comparison group ( age 42..n=2,000)

p< .001..7X increased risk Preuss/Schuckit Am J Psych 03

What Predicted Suicide Attempts in Alcoholics (n=1,237) over 5 years?Rate = 4.5% attempted suicidePrior attemptsEarlier onset and more severe dependence. Other drug dependenceSeparated or divorcedMore likely to have had treatment ( more severe)More PanicMore Substance Induced Psych Disorder Preuss/Schuckit et al Am J Psych03

ALCOHOL USE IN THE U.S.Two-thirds of all adults drink alcoholOne-third of all high-school seniors are heavy drinkersAmericans over the age of 14 drink 2.54 gallons of pure alcohol per year (down from 2.75 in 1981)Twenty percent of people who sample alcohol become dependent

Substance Induced Depression: Severity/DangerousnessHenriksson, et al (1993)- 43% of completed suicides had alcohol dependence. 48% of these were also depressed. 42% had a personality disorder.

Elliot, et al (1996)- patients with medically severe suicide attempts had a statistically higher prevalence or substance-induced mood disorder.

Pages K et al (1997)- Higher degrees of Sub Dep related to higher severity suicide ratings

VITAL STATUS: Cumulative Survival after State Hosp Admission-Wa StateMaynard & Cox, 2003

AGE ADJUSTED DEATH RATE:Number of Deaths per 1000 per Year Maynard & Cox, 2003

Harborview Study: How do Suicide and Addiction issues relate in Acute Psychiatric Admissions?What characterizes those with severe suicide ratings?

How does severity of substance use relate to severity of suicide intent?

What about Substance Induced syndromes as they relate to suicide intent?

How do substance issues affect rates of AMA, Length of Stay, and Involuntary Treatment in highly suicidal admissions?

Harborview StudyMethods: Attendings rate illness severities across 30 items on all admits and discharges, as part of standard clinical noteSubstance rating=0= no substance use problems

1,2= substance use has led to only minor/infreq problems such as moodiness etc

3,4= qualifies for Substance Abuse with problems, but not dependence

5,6 = qualifies for dependence with compulsive use, consequences, and loss of control

HARBORVIEW MEDICAL CENTERINPATIENT DATA BASE 1996-2003SUICIDE STUDY

RELATIONSHIP OF ALCOHOL & DRUG PROBLEMSTO SEVERE SUICIDALITY (n=12,196)ALCOHOL OR DRUG PROBLEMSPercent With Severe Suicide RatingWalds = 235.41 p < .001Ries & Russo, 2003ODDS adjusted for age & gender

RELATIONSHIP OF SUICIDE TO PSYCHIATRIC DIAGNOSIS AND SUBSTANCE DEPENDENCEPercent With Severe Suicide RatingRies & Russo, 2003

RELATIONSHIP OF SIMD TOSUICIDE SEVERITY (n=12,492)% Substance Induced Mood DisorderPercent With Severe Suicide RatingWalds = 216.63 p < .001Ries & Russo, 2003ODDS adjusted for age & gender

INPATIENTS WITH SEVERE SUICIDALITY(5 or 6) N=4037 (From 1996-2003)Ries & Russo, 2003

In an acute suicidal inpatient with mood lability, impulsivity and substance use is it: Major Depression, Bipolar Disorder or Substance Induced Mood Disorder ?Can Clinicians tell the difference?.............Yes Ries 01Can Researchers tell the difference?.........Yes Hasin 97 What is Comparative Lethality? ..At least equal, maybe >What are the Managed care implications? Eg: Maj Dep vs Sub Ind Mood Payment (Lots)!....Length of Stay ( 2 vs. 6-8 days)** ASAM conf survey Ries unpub 03

Would the treatment approaches differ?YES

On Many Acute Psychiatric Units:As Psychiatric Inpts, Substance Induced Mood pts often get Dxd with Major Depression, Depression NOS, Bipolar Depression, Bipolar II etc and Started on meds..*

Because:It justifies managed care review ( payment)Its what most Psychiatrists know how to doOften saying meds shouldnt hurt, but might help .even if the doctor thinks SIMD is most likely Dx* ASAM Conf survey , Ries unpub 03

Suicide rates in clinical trials of SSRIs, other antidepressants, and placebo: analysis of FDA reports. Khan A, Khan S, Kolts R, Brown WA. METHOD: Food and Drug Administration (FDA) summary reports of the controlled clinical trials for nine modern FDA-approved antidepressants provided data for comparing rates of suicide.

RESULTS: Of 48,277 depressed patients participating in the trials, 77 committed suicide. Based on patient exposure years, similar suicide rates were seen among those randomly assigned to an SSRI (0.59%, 95% confidence interval [CI]=0.31%-0.87%), a standard comparison antidepressant (0.76%, 95% CI=0.49%-1.03%), or placebo (0.45%, 95% CI=0.01%-0.89%).

CONCLUSIONS: These findings fail to support .1. an overall difference in suicide risk between antidepressant- and placebo-treated depressed subjects in controlled trials or2. a difference between SSRIs and either other types of antidepressants or placebo.

Do anti-depressants treat or decrease Suicidality?

Am J Psychiatry. 2003 Apr;160(4):790-2.

However at Discharge:The pt now carries dx of major depression or Bipolar II etc, ON MEDS, with recent suicide attempt.(and soon may be on the way to SSI MH disability, with funds to use for Alc/Drugs).Satel 97

At Discharge, MAJOR PSYCH DX ON MEDS often means referral to either MHC or Primary Care prescriber.neither of which offers what SIMD pts really NEED

Which is Primary Addiction Treatment, at a site which can tolerate such recently suicidal patients and provide meds if needed

Can addiction treatment affect suicidality?Cohort suicide attempts year prior year after

Adults > 25 yo (n=3524) 23%...........................4%18-24 yo (N=651) 28%...........................4% Adoles (n=236) 23%...........................7%

Karageorge: National Treatment Improvement Evaluation study 2001

Implications of SIMD MisdiagnosisClinical databases that dont include SIMD

Overestimation of Psychiatric Disorders, such as Bipolar both clinically and in Research studies if using non-sophisticated instruments

Misdirected treatment of 1 addiction disorders as Bipolar II etc

Unnecessary, expensive, and potentially medically risky medications

More suicide attempts if not sober

Policy Implications for the Mental Health system Most or all acute psych units need to be Dual DX units, i.e., have a serious degree of integrated substance intervention since about half of their admissions are CODHow many acute psych units really are COD enhanced?

Greatly increased Addictions training in psychiatrists, counsleors, and other staff.

Revise the Length of Stay, Payment and Managed Care policies which drive misdiagnosis and mistreatment.What are actual Federal ( Medicare), State Medicaid, and Insurance and Managed Care policies?

Researchers need to use instruments like the PRISM ( Hasin D, et al.) and factor substance use issues into analyses of suicide and other problem behaviors

Policy Implications for Addiction Treatment SystemAcknowledge that about half of their pts have been or are suicidal and train staff accordingly.What type of suicide assessment strategies are needed for substance related cases?

Acknowledge that these pts are just as lethal, often more so in the long run than most MH or SMI pts,Need to get this message out through more research , publication etc viz recent Alc ClinExp Res, but do counselors read this?

Acknowledge that a protective suicide intervention is sobriety, but focused suicide prevention methods are neededWhat are the best suicide prevention methods that addiction agencies could use? However, if MH dx is blatant and interferes with Addiction Treatment, then provide integrated medications management on site (only about 10- 40 % of the addictions programs in the USA have this)More studies of quadrant 3 dual interventions are needed

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/

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

The combination of depression and drugs alcohol is more deadly, even if it may be shorter in duration.