Suicide and Alaska-some special topics

Richard Ries MD

rries@u.washington.eduHarborview Medical Center and

the University of WashingtonSeattle, Washington

RRies Addiction and Suicide

Ries Conflict of Interest Statement

Dr Ries is on Speaker’s bureaus for Janssen, and Alkermes

Dr Ries has Grant funding from: NIH- NIDA

Contingency Management Meth in Mentally Ill Preventing Addiction Related Suicide Brief Interventions of Drug Abuse in Prim Care

CSAT National Co-occurring Center of Excellence

DOD- Suicide Prevention grant

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

Some 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

Facts about Suicide:

Risk and Lethality Risk of Attempt

Previous attempt Family History of

Suicide Psychiatric disorder Alcohol/Drug disorder Alcohol/Drug

Intoxication Loss Hopelessness/end of

rope

Risk of Lethality Male 4/1 over

females Guns 70%

Access Older >70 Alone/Loss of support Alcohol Serious illness

Medical Psychiatric

USA Number ofSuicide Deaths

PopulationCrudeRate

Age-AdjustedRate**

36,909 307,006,550 12.02 11.77

 2009, United States

Suicide Injury Deaths and Rates per 100,000 All Races, Both Sexes, All Ages

ICD-10 Codes: X60-X84, Y87.0,*U03

 

Alaska 143

698,473 20.47 19.39

143 698,473 20.47          

Idaho

3041,545,801 19.67 20.42

304 1,545,801 19.67          

Washington 921

6,664,195 13.82 13.38

921 6,664,195 13.82

Oregon 644

3,825,657 16.83 16.11

644 3,825,657 16.83          

HOW U.S. SOLDIERS DIECombat

3%Undetermined

1%Homicide

4%

Illness25%

Suicide17%

Accident50%

Suicide accounted for an average of nearly 1 in 5 deaths among regular and reserve U.S. military personnel between October 1998 and September 2003.

Source: U.S. Armed Forces Medical Examiner, 2004

J Sch Health. 2004 May;74(5):177-82.

Attempted Suicide and associated health risk behaviors among Native American high school students. Shaughnessy L, Doshi SR,

The study included students in BIA-funded high schools with 10 or more students enrolled in grades 9-12. Overall, 16% of BIA high school students attempted suicide one or more times in the 12 months preceding the survey.

Risk Factors:

> unintentional injury and violence behaviors, > sexual risk behaviors, > tobacco use, and > alcohol and other drug use.

Lifetime Suicide risk for Schizophrenic, Affective and Addiction Disorders:

Method: review of 83 mortality studies:

Schizophrenia…………4%

Affective Disorders……6%

Addiction Disorders…...7%

Inskip HM: Br J Psych 1998

What about Addiction and Suicide ?

Alcohol strongest predictor of completed suicide over 5-10 years after attempt, OR= 5.18…vs. 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)

Is Suicide also Addictions Territory?

Modality Percents

2%

28%

9%39%

IPOPMMDetox

25%20% 18% 20%

17%13% 11% 13%

0%

10%

20%

30%

40%

IP OP MM Detox

% Thoughts % Attempted

Lifetime Suicide Thoughts/Attempts

N=60,952

8% 5% 4%9%

2% 1% 1% 2%0%

10%

20%

30%

40%

IP OP MM Detox

% Thoughts % Attempted

Past 30 days Suicide Thoughts/Attempts

N=60,952

4.5% 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……….. 700 % increased risk of Suicide Attempts

Preuss/Schuckit Am J Psych 03

What do we know about Suicide Attempts in Prospective Age-Matched Alcoholic

Populations

Rate = 4.5% attempted suicide Prior attempts Earlier onset and more severe dependence.

Other drug dependence Separated or divorced More likely to have had treatment ( more

severe) More Panic More Substance Induced Psych Disorder

Preuss/Schuckit et al Am J

Psych03

What Predicted Suicide Attempts in Alcoholics (n=1,237) over 5

years?

1: Drug Alcohol Rev. 2005 May;24(3):203-8.

Alcohol and suicide at the population level--the Canadian experience.Ramstedt M.

Studies suggest that the population level link between alcohol and suicide differs across countries and between men and women. The aim of this paper was to estimate the relationship between alcohol consumption and suicide in Canada and to put the results in a comparative perspective.

The total suicide rate in Canada increased significantly by around 4% as alcohol consumption increased by one litre per capita, suggesting that approximately 25 - 30% of Canadian suicides were related to alcohol.

Su

icid

e in

Men

Su

icid

e in

Wo

men

Men Women Alcohol Consumption

Standardized suicide mortality rates in men and women with mean annual alcohol consumption in liters per capita.

Russia 1965-99.

Su

icid

e R

ates

per

100

,000

Alc

oh

ol

con

sum

pti

on

BAC Positive Suicides

BAC Negative Suicides

Alcohol Consumption

Mean annual consumption with BAC-positives and BAC-negatives for 8 Russian Regions 1981-1990.

Henriksson, 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

Substance Induced Depression: Severity/Dangerousness

METH ADDICTS: LIFETIME SUICIDE ATTEMPTS, BEHAVIOR PROBLEMS, AND FELONY CHARGES, BY GENDER

ASI ItemASI Item OverallOverall MalesMales FemalesFemales Test Test Statistic*Statistic*

Attempted Suicide (%)Attempted Suicide (%) 27%27% 13%13% 28%28% 35.42**35.42**

Violent behavior problems (%)Violent behavior problems (%) 43%43% 40%40% 46%46% 3.29***3.29***

Assault Charges (mean number)Assault Charges (mean number) 0.290.29 0.460.46 0.150.15 4.46**4.46**

Weapons charges (mean number)Weapons charges (mean number) 0.130.13 0.210.21 0.070.07 4.09**4.09**

*Mantel-Haenszel chi-square was used to test differences in proportions by gender, df=1; *Mantel-Haenszel chi-square was used to test differences in proportions by gender, df=1; Student’s two-group t-test (two-sided) was used to test differences between males and females in Student’s two-group t-test (two-sided) was used to test differences between males and females in continuous dependent variables reflecting the number of charges, df=1013. continuous dependent variables reflecting the number of charges, df=1013.

**p < 0.00001 ***0.1 **p < 0.00001 ***0.1 << p <0.05 p <0.05Zweben, et al., 2004

DoDo Anti-depressants treat OR decrease “Anti-depressants treat OR decrease “SuicidalitySuicidality”?”?

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

Suicide rates in clinical trials of SSRIs, other antidepressants, and placebo: analysis of FDA reports.Khan A, Khan S, Kolts R, Brown WA.

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 either an overall difference in suicide risk between antidepressant- and placebo-treated depressed subjects in controlled trials or a difference between SSRIs and either other types of antidepressants or placebo.

Cohort suicide attempts

Adults Year Prior Year After> 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

Can addiction treatment affect suicidality?

Alcohol Consumption, Alcoholics Anonymous membership, and Suicide MortalityRates, Ontario, 1968-1991.Mann RE, Zalcman RF, Smart RG, Rush BR, Suurvali H.

Method: We studied the impact of alcohol consumption levels, AA membershiprates, and unemployment rates on suicide mortality rates in Ontario from 1968 to1991. Results:

Total alcohol consumption was significantly and positively related to total and female suicide mortality rates. AA membership rates were negatively related to total and female suicide rates.

(J. Stud. Alcohol 67: 445-453, 2006).

Opioid Related Death Opiates and Opioids have the highest death rates of any

psychoactive illicit-substances Accidental deaths from Prescription Opioids now

Outnumber Traffic deaths in many states

The 2010 CDC report, Unintentional drug poisoning in the United states, sites heroin and prescription painkillers as the two leading causes of overdose death in the US

Hulse, English, Mline, & Holman, 1999; Seymour et al. 2000, CDC 2010, 2012

Overdose Planned Overdose Planned LethalityLethality

Fully accidental

Just blot out worries

Who cares if I wake

Lethal Plan

Mortality rate of opioid users 14 times that of general population

46% to 70% of opioid users experience one or more non-lethal overdoses during their lifetime

Opiate users who were recently released from prison were at even higher risk of overdose, and this risk may also exist post “Detox”

Opioid Deaths

1 in 5 (20%) of suicide victims have opiates in their bodies at time of death, including heroin, and prescription painkillers

Opioid dependent adults are 14 times more likely that their non-drug using counterparts to die by suicide Between 33% and 50% of drug users have a history of suicide attempts

Suicide accounts for an estimated 3% to 35% of deaths among heroin users

Spectrum of Volition— Accidental -- Risky -- Passive SI -- Planned Suicide

Suicide and Opiates

Harris and Barraclough, 1997; Darke and Ross, 2002, Ries SPOT unpub

Risk Factors for Suicide in Opiate Abusers Parallel Risk Factors for Accidental Overdose(Darke and Ross, 2002)

AccidentalOverdose

Suicide

Male gender

DepressionPreviousattempt

Previousoverdose

Personality Disorder: CCD ASPD

Hx. of childhoodsexual trauma

Homelessness Social isolation

Poly-substance abuseGenetic predisposition

Prevention of Fatal overdose Methadone: opiate replacement therapies

reduce opiate overdose risk by 75% Naloxone: ER administered Naloxone, peer

administered Naloxone (I.M., I.V., S.Q., intranasil). Medically supervised injection facilities:

report 0 fatal overdose deaths. Educational programs: presented at needle

exchange programs Protocols: limiting police intervention in during

overdose emergencies

Evidence Supported Overdose Prevention

Programs

Gunne and Gronbladhm, 1981; Bammer, 2000; McGregor, Ali Christie, Darke, 2001

Designed to be a single 3 hour IOP session integrated into typical outpt Addictions Treatment programs—for all patients in treatment

To enhance positive changes in Attitudes, Knowledge,

and Adaptive Skills for suicidal issues in both patients and those around them, workbook based,

Needing only a single 3 hour staff training session—using same guide they then use to perform and guide group.

Designed iterively with REAL WORLD addictions staff, administrators, and patients for feasabiity

RETRAINS STAFF EACH TIME USED IN IOP, OR OTHER FORMAT

Preventing Addiction Related Suicie (PARS)

NIDA R21Ries, Voss, Comtois,

Addictions staff and directors

In the past 30 days, have you asked a friend to get help because you were worried that he or she was having suicidal thoughts/feelings.

 

Pre-test NO YES94%

(n=59)6%

(n=4)1-month follow-up

78% (n=49)

22% (n=14)

P=.009

Pilot Data PARS In the past 30 days, have you asked for help because you were having suicidal thoughts/feelings.

 

Pre-test No97%

(n=60)

YES3%

(n=2)

1 month follow-up

90% (n=56)

10% (n=6)

P=.000

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/

CDC

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

Tip 50- Addiction and Suicide www.CSAT.gov

Suicide Resources:

Suicide Assessment

Suicide prevention

Suicide Treatment

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