suicide risk and c0-occuring disorders scdmh medical directors skill maintainence initiative...

Suicide Risk and Suicide Risk and C0-Occuring DisordersC0-Occuring Disorders

SCDMH Medical DirectorsSCDMH Medical DirectorsSkill Maintainence InitiativeSkill Maintainence Initiative

11-16-201111-16-2011

Robert Breen MDRobert Breen MDMedical Director Medical Director

Bryan Psychiatric HospitalBryan Psychiatric HospitalDIS-SCDMHDIS-SCDMH

Suicide Risk and Co-Occuring DisordersSuicide Risk and Co-Occuring Disorders

1.1. Examine how substance Examine how substance abuse affects suicide riskabuse affects suicide risk

2.2. Examine suicide risk in Examine suicide risk in different components of the different components of the four quadrant modelfour quadrant model

3.3. Describe available suicide Describe available suicide risk management options risk management options for persons needing for persons needing substance abuse treatmentsubstance abuse treatment

Suicide Rate in SC 2001-2008 Suicide Rate in SC 2001-2008 YearYear NumberNumber RateRate

20012001 473473

20022002 466466

20032003 496496

20042004 483483 11.611.6

20052005 503503 12.212.2

20062006 533533 11.711.7

20072007 529529

20082008 542542 12.012.0

SCVDRS and CDC

JamisonJamison

19991999

How does Substance Abuse How does Substance Abuse

Interact with Interact with

Suicide RiskSuicide Risk

Suicide Risk and Substance AbuseSuicide Risk and Substance Abuse


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 IllnessNational Association of State Mental Health Program DirectorsMedical Directors Council March 2008

Alcohol and drugs can:Alcohol and drugs can:

– Deplete serotonin, dopamine and other Deplete serotonin, dopamine and other neurotransmitters linked to suicideneurotransmitters linked to suicide


Drugs to overdose by:Drugs to overdose by:

– OpiatesOpiates

– CocaineCocaine

– BenzodiazepinesBenzodiazepines

– InhalantsInhalants



Alcohol’s 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 50 2009


Depression is a common co-occurring diagnosis among people who abuse substances that confers risk for suicidal behavior

Other mental disorders are also implicated.



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.


Alcohol can increase suicide risk by:Alcohol can increase suicide risk by:

– Makes it easier to go ahead with an Makes it easier to go ahead with an attemptattempt

– Makes attempts more lethalMakes attempts more lethal

– Interferes with effective problem solving Interferes with effective problem solving skillsskills


Characteristics of the Person with Alcohol Characteristics of the Person with Alcohol Problems who SuicidesProblems who Suicides

Started drinking at young ageStarted drinking at young age

Consumed alcohol over long period of timeConsumed alcohol over long period of time

Drank heavilyDrank heavily

Poor physical healthPoor physical health

DepressedDepressed

Disturbed and chaotic livesDisturbed and chaotic lives

Recent interpersonal lossRecent interpersonal loss

Performed poorly at workPerformed poorly at work

Family history of alcoholismFamily history of alcoholismAdapted from World Health Organization 2000Adapted from World Health Organization 2000

Studies in Denmark and the USSR Studies in Denmark and the USSR demonstrated that suicide rates demonstrated that suicide rates decreased with more restrictive decreased with more restrictive alcohol policiesalcohol policies

While in the US increases in alcohol While in the US increases in alcohol consumption correlate with increase consumption correlate with increase in suicide ratesin suicide rates


Risk ClustersRisk Clusters1. Mental illness + 1. Mental illness + Alcohol problemsAlcohol problems2. Mental illness + recent Crisis2. Mental illness + recent Crisis3. Mental illness only3. Mental illness only4. Depression + Financial problems4. Depression + Financial problems (little treatment)(little treatment)

5. 5. Alcohol problemsAlcohol problems + Stressors + Stressors (some depression)(some depression)

6. Depression + MEDICAL PROBLEMS 6. Depression + MEDICAL PROBLEMS (little treatment)(little treatment)

7. Legal problems + recent Crisis 7. Legal problems + recent Crisis (interpersonal (interpersonal problems)problems)

8. Interpersonal problems + recent Crisis + 8. Interpersonal problems + recent Crisis + AlcoholAlcohol

9. 9. Alcohol IntoxicationAlcohol Intoxication at the time of death at the time of death (dependence)(dependence)

Suicide Categories by Patterns of Known Risk Factors: Suicide Categories by Patterns of Known Risk Factors: A Latent Class AnalysisA Latent Class Analysis

Logan, Hall, Karch.Logan, Hall, Karch.Arch Gen Psychiatry 2011;68(9): 935-941 Arch Gen Psychiatry 2011;68(9): 935-941

National Suicide Prevention HotlineNational Suicide Prevention HotlineCore PrinciplesCore Principles

Suicide and Life-Threatening Behavior 37(3) June 2007 353The American Association of Suicidology

SUICIDE SUICIDE SUCIDE SUCIDE SUICIDAL SUICIDAL BUFFERS/ BUFFERS/ DESIRE DESIRE CAPABILITY CAPABILITY INTENT CONECTEDNESS INTENT CONECTEDNESS

IdeationIdeation Attempt history Attempt history Attempt Attempt Immediate SupportsImmediate Supportsin progressin progress

Psychological Psychological Violence history Violence history Social supports Social supports painpain

Hopelessness Hopelessness Available means Available means Plan Plan Planning for the futurePlanning for the future method knownmethod known

Perceived burdenPerceived burden IntoxicatedIntoxicated Engagement Engagement

Feeling trapped Feeling trapped Substance abuseSubstance abuse PreparatoryPreparatory Ambivalence Ambivalencebehaviorsbehaviors

Intolerably alone Intolerably alone Psych symptomsPsych symptoms Core values beliefs Core values beliefs

Agitation/rageAgitation/rage ExpressedExpressed Sense of purpose Sense of purposeintent to dieintent to die

The CTS Suicide EquationThe CTS Suicide Equation

Desire X Intent

----------------------------- X Capability

Buffers

The Suicide EquationThe Suicide Equation

Pain X Hopelessness

----------------------------- X CAPABILITY Connectedness

Suicide and SubstanceSuicide and Substance

Abuse in Abuse in

South CarolinaSouth Carolina


2003 Suicide in South Carolina2003 Suicide in South Carolina

Adolescent male with interpersonal Adolescent male with interpersonal problem, problem, probable substance abuseprobable substance abuse but but possibly “not depressed” and not treatedpossibly “not depressed” and not treated

Adult male with intimate partner problem, Adult male with intimate partner problem, probable mental illness, possibly in probable mental illness, possibly in treatment, treatment, possible substance abusepossible substance abuse

Elderly male with physical problems, Elderly male with physical problems, depressed, but likely not acknowledging depressed, but likely not acknowledging depression and not in treatmentdepression and not in treatment


Age 1-17Age 1-17

50% 50% Interpersonal problem Interpersonal problem

38% 38% Substance abuse Substance abuse problemproblem

25%25% Depressed mood Depressed mood

25% 25% Mental health problem Mental health problem

12.5% Current mental health tx.12.5% Current mental health tx.SC-DHEC- SCDVRSSC-DHEC- SCDVRS


Age 24-54Age 24-54

58.7% 58.7% Depressed mood Depressed mood 39.8% 39.8% Mental health problem Mental health problem37.8% 37.8% Problem with partner Problem with partner18.9% 18.9% Alcohol problem Alcohol problem18.1% 18.1% Physical health problem Physical health problem

37.4% 37.4% Current mental health tx. Current mental health tx.

SC-DHEC- SCDVRSSC-DHEC- SCDVRS


Age 55-olderAge 55-older

63.3% 63.3% Physical health problem Physical health problem

62.6%62.6% Depressed mood Depressed mood

31.7% 31.7% Mental health problem Mental health problem

18.1% 18.1% Current mental health tx. Current mental health tx.

SC-DHEC- SCDVRSSC-DHEC- SCDVRS

Suicide Risk In the ElderlySuicide Risk In the ElderlyADDITIONAL RISK FACTORS ADDITIONAL RISK FACTORS

FOR SUICIDE IN OLDER PERSONSFOR SUICIDE IN OLDER PERSONS

Heavy alcohol use Heavy alcohol use

Presence of mental disorders in addition to depression Presence of mental disorders in addition to depression

Presence of a serious physical illness Presence of a serious physical illness

Social isolation, particularly after the death of a spouse or Social isolation, particularly after the death of a spouse or close friend close friend

Access to firearmsAccess to firearms

JAMA Patient Page JAMA Patient Page Vol. 291 No. 9, March 3, 2004Vol. 291 No. 9, March 3, 2004

Suicide Risk in theSuicide Risk in the

South CarolinaSouth Carolina

Public SectorPublic Sector


Risk clusters from SCDMH reportsRisk clusters from SCDMH reports

Cluster 1Cluster 1White, maleWhite, maleMood disorderMood disorderLost wife or girl friendLost wife or girl friendLost income:Lost income:

Cannot keep a jobCannot keep a job Disability assistance turned downDisability assistance turned down

Suffering from chronic painSuffering from chronic painAlcohol/ substance abuseAlcohol/ substance abuseYoung adult male about to go to jail (again)Young adult male about to go to jail (again)Methods: Gunshot , HangingMethods: Gunshot , Hanging


Cluster 2Cluster 2

Schizophrenia (CUS)Schizophrenia (CUS)

Male or female Male or female

Occurs without warningOccurs without warning

With or without depression With or without depression

Methods: Struck by trainMethods: Struck by train

Leaping in front of moving trucks/carsLeaping in front of moving trucks/cars

Leaping from overpass onto roadwayLeaping from overpass onto roadway


Cluster 3Cluster 3

FemaleFemale

Mood Disorder, especially Major DepressionMood Disorder, especially Major Depression

Substance abuse, addiction to Substance abuse, addiction to Rx medicationsRx medications

Personal Health Issues (e.g., cancer)Personal Health Issues (e.g., cancer)

Unresolved early-age trauma?Unresolved early-age trauma?

Method: Method: OverdoseOverdose


Cluster 4Cluster 4

Either sex, grieving over lost/dead friend or childEither sex, grieving over lost/dead friend or child

Major DepressionMajor Depression

Alcohol is prominent coping mechanismAlcohol is prominent coping mechanism

Believes she/he can be reunited with the lost Believes she/he can be reunited with the lost one in death (this may be a covert belief)one in death (this may be a covert belief)

Method: Gunshot, often near the grave of the Method: Gunshot, often near the grave of the lost onelost one


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 IllnessNational Association of State Mental Health Program DirectorsMedical Directors Council March 2008

Suicide Risk AssessmentSuicide Risk Assessment



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 client’s 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


Suicide Risk and Co-Occurring DisordersSuicide Risk and Co-Occurring DisordersThe Four Quadrant ModelThe Four Quadrant Model



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


Quadrant’s II and III would have elevated suicide risk and should be screened for suicide risk factors when life stressors/losses occur


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.

Crisis Suicide AssessmentCrisis Suicide Assessment

Safety PlanMust be willing to engage in treatment!

Get patient’s commitment to follow-up assessment!

Must not have impulsive access to method!

Must have responsible others to monitor for worseningwho willingly collaborate on safety plan!

Must agree to not use alcohol and/or street drugs!

Ask about firearms!

The End

Suicide Risk and Suicide Risk and Substance AbuseSubstance Abuse

suicide risk and c0-occuring disorders scdmh medical directors skill maintainence initiative...

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