Title: Suicidal Behavior, Alcohol, and Alcohol Use Disorders <Slide 1>

Timothy W. Lineberry, M.D.

Alcohol Medical Scholars Program 3-14-08

 

I.    Introduction

      A.  Suicidal behavior is prevalent <Slide2 >

            1.   U.S. population 2006 =300 Million → suicidal thoughts (SI): 3.3%/yr 1

            2.   Annual prevalence suicide attempts: 0.6%

            3.   Lifetime prevalence of attempts: 4.6%

            4.   > 32,000 die by suicide/yr ↔ 1.4% of all U.S. deaths2 ↔ 0.01%/yr

      B.   Alcohol (alc) misuse is common <Slide 3>

            1.   U.S. adult population: ~ 90% lifetime alc use / 53% use alc past yr3

            2.   “Hazardous drinkers”→ (>5 drinks/day) : ~ 25% past yr 4, 5

            3.   Alc abuse prevalence (DSM-IV defined)6

                  a.   18% lifetime: men > women (~2:1)

                  b.   5% 12-month prevalence

            4.   Alc dependence prevalence (DSM-IV defined)6

                  a.   13% lifetime: men > women (~2:1)

                  b.   4% 12-month prevalence  

      C.  Alc use and suicidal behaviors often co-occur (more details later)

            1.   Acute use:  alc in ~ 40% attempts/completed suicide7

            2.   Alc abuse/dependence diagnosis (dx): present in ~25% all suicides8

      D.  This lecture answers 4 questions <Slide 4>

            1.   Definitions of alc misuse, major depression (MDD), & suicide-related behaviors

            2.   Relationships between alc dependence, MDD, and suicide-related behavior

            3.   How to screen and identify “at risk” patients

            4.   How to initially assess and manage “at risk” patients

II.   Definitions of alc misuse, MDD, and suicide-related behaviors        

      A.  Definitions regarding alcohol

            1.   At-risk/hazardous drinking <Slide 5>

                  a.   Potential alc use problems -- not abuse or dependence dx

                        i.    Men ≥ 5 drinks/day or ≥ 15 drinks/wk

                        ii.    Women ≥ 4 drinks/day and ≥ 8 drinks/wk

                        iii.   Risk for alcohol-related problems ↑ at those limits

            2.   Abuse - Repeated alc problems over 12 months with ≥ 1 of: <Slide 6>

                  a.   Inability to fulfill role obligations

                  b.   Use in physically hazardous situations 

                  c.   Legal problems

                  d.   Social or interpersonal problems

                  e.   Not dependence

            3.   Dependence - Repeated problems over 12 months with ≥ 3 of:  <Slide 7>

                  a.   Tolerance: ↑ use for same effect; ↓ effect with same amount used

                  b.   Withdrawal syndrome:  Use alc to ↓ symptoms

                  c.   Use larger/longer than intended

                  d.   Desire or unsuccessful efforts to cut down

                  e.   ↑ time spent in alcohol-related activities

                  f.    Give up important activities

                  g.   Continued use despite persistent problems

      B.   Definitions regarding MDD

            1.   MDD lifetime prevalence:  ♀ 15%: ♂ 8% <Slide 8>

                  a.   > 5  following symptoms nearly every day during 2-week period (see below)

                  b.   Represents change from previous functioning

                  c.   May be subjective report or observation of others

                  d.   Must have at least depressed mood and/or ↓ interest or pleasure (i. or ii.)

                        i.    Depressed mood most of the day

                        ii.    Markedly diminished interest or pleasure in all or almost all activities

                        iii.   Weight loss or weight gain or ↓ or ↑ in appetite <Slide 9>

                        iv. ↓ Or ↑ in sleep

                        v.   Psychomotor agitation or retardation

                        vi.   Fatigue or ↓ energy

                        vii.  Feelings of worthlessness or excessive/inappropriate guilt

                        viii.↓ Ability to think/concentrate or indecisiveness

                        ix.   Recurrent thoughts of death or recurrent SI +/- specific plan or attempt

      C.  Definitions regarding suicide-related behavior <Slide 10>

            1.   Suicidal ideation (SI) = thoughts of suicide

            2.   Suicide attempt = deliberate self-harm with intent to die

                  3.   Completed suicide = deliberate self-harm resulting in death

III. What are relationships of alc, MDD, and suicide related behavior? <Slide 11>

      A.. Prevalence of suicide-related behaviors with alc use disorders <Slide 12>

            1.   Alcohol use disorders: ~25% all suicides (psych autopsy)8

            2.   Suicidal ideation (SI) in alc dependence: ↑ 3-5 X vs. Gen. Pop. 9 <Slide 13>

            3.   Suicide attempts in alc dependence: ↑ 4-6 X vs. Gen. Pop.

            4.   Completed suicide in alc dependence: 7%10  

      B.   Prevalence of suicide-related behaviors with MDD <Slide 14>

            1.   Suicide & depression: ~40 of all suicides (psychological autopsy)8

            2.   Suicide attempts in major depression: 20% with lifetime attempt <Slide 15>

            3.   Suicide in depression → varies with severity of illness 11                                                                   a.      Psychiatric inpatient + SI:  9% suicide/lifetime

                  b.   Inpt without SI:  4% suicide/lifetime

                  c.   Outpatient depression:  2% suicide/lifetime       

      C.  Alc dependence + depression12-14