Title:  Acute Alcohol Use and Suicide Attempts

Courtney L. Bagge, Ph.D.

Department of Psychiatry and Human Behavior

University of Mississippi Medical Center

Alcohol Medical Scholars Program (Slide 1)

I.        Introduction

A.      Suicidal behavior is common in US (Slide 2)

                                                            1.      > 36,000 die by suicide   

                                                            2.      10th cause of death in US1

                                                            3.      ~5 nonfatal attempts per 1 completion2  

B.      Alcohol use & misuse also common in US (Slide 3)

                                                            1.      ~ 90%  use alc lifetime          

                                                            2.      53% use alc past yr3

3.    15% lifetime abuse4 (I define later)

4.    10% lifetime dependence4

C.      There is overlap: use, misuse, attempt (Slide 4)

1.      Attempters who acutely use prior to act:  ~30% have AUD9

2.      Attempters w/ AUD: ~70% acutely use prior to act6

D.     Clinical Case Eg: Is person at risk for alcohol-related suicide? (Slide 5)

                                                            1.      Visits primary care physician for check-up

                                                            2.      30 yr. old female

                                                            3.      Drinking: 1 X every 2 mo. (1-2 drinks)

                                                            4.      No suicidal thoughts

                                                            5.      No history of depression (known risk factor for suicide)

                                                            6.      Mentions relationship difficulties

E.      This lecture will cover: (Slide 6)

                                                            1.      Definitions of suicidality and chronic/acute alcohol use

                                                            2.      How acute alcohol use and suicide attempts relate

                                                            3.      Possible reasons for drinking at attempt

                                                            4.      Prevention and treatment implications

II.      Definitions

A.      Suicidality (Slide 7)

1.      Suicidal thoughts (or ideation):Thoughts of killing oneself

2.      Suicidal behavior: Self-inflicted behavior w/intent to die

a.      Suicide: Fatal outcome

b.      Attempt: Non-fatal outcome

B.      Alcohol

                                                            1.      Drink (10-12g ethanol) (Slide 8)

a.      Beer: 12 oz/355 ml

b.      Wine: 4 oz/120 ml

c.       Spirits (gin): 1.5 oz/44 ml

                                                            2.      Drinking patterns (Slide 9)

a.      Quantity frequency   

b.      Heavy episodic7

   5+ drinks/session

   4+ drinks/session

                                                            3.      Binge15:

a.      Prolonged exposure: Intoxicated > 2 days

b.      Give up usual activities for intoxication

                                                            4.      Alcohol Use Disorders (AUD)16 (Slide 10)

a.      Alcohol abuse: Repeated alc problems in same 12 mo. with ≥ 1 of:

   Inability to fulfill role obligation

  Use in physically hazardous situations (eg, driving)

   Legal problems

  Social or interpersonal problems

   Not dependence

b.      Alcohol dependence: Repeated alc problems over 12 mo. w/ ≥ 3 of:

   Tolerance: ↑ use for same effect; ↓ effect w/same amount

   Withdrawal: Symptoms opposite of intake

   Use heavier or longer than intended

   Desire and inability to cut down

   ↓ activities in order to drink

   Much time spent in alcohol-related activities

   Ongoing use despite consequences

                                                            5.      Acute alcohol use (Slide 11)

a.      For alcohol: Any 1 instance of drinking

b.      For suicide: 1 specific instance of drinking (prior to attempt)

                   Drinking any alcohol   

                   Drinking to intoxication

        Usually within 3-6 hours of attempt 

III.    How  acute alcohol use and suicide attempts relate (Slide 12)

A.      Descriptive statistics  use on day of attempt (Slide 13)

                    1. ~ 40%5  attempters used alcohol on attempt day  

                    2. Subgroups differ re use on that day17,18

a.      Men (53%) > women (40%)

b.      < age 51 greater than older ages  

c.       AUD

3. Limitations

d.      Rates only descriptive (No control group)

e.      Not evidence of association

B.      Case-control research: Who is likely to attempt? (Slide 14)

                                                            1.      Design19

a.      Compare 2 groups on recent alcohol exposure

b.      E.g., ER patients: after attempt vs. non-suicidal injury

                                                            2.      Key findings (Slide 15)

a.      Risk ↑ with higher dose10

b.      Acute use of > 100 grams → ~60X ↑ risk 10

c.       Chronic use of > 100 grams/day → 3X ↑ risk  10

d.      Modeled together:  Acute use risk ≥than chronic use

   Acute use: > effect (OR = ~6, p < .05)11

  Chronic use no longer risk

                                                            3.      Design Limitations

a.      No consensus who best control group

b.      Can’t control for all case-control differences (e.g., race, age, SES, etc.)

C.      Case-crossover studies: When is someone likely to attempt? (Slide 16)

                                                            1.      Design15

a.      Compare 1 person on 2 occasions/periods

b.      E.g., 6 hrs. prior to attempt vs. matched 6 hrs. prior period

c.       Best control group patient himself

                                                            2.      Key findings: (Slide 17)

a.      ↑ attempt risk while drinking (large effect; RR=~10x) 21

b.      Occurs regardless of sex, age, marital status21

c.       So, acute drink ↑ risk 4 all but…

d.      Acute drinking ↑ risk infrequent drinkers (< 1/ mo.) than others21

e.      Highlights clinical importance esp. for infrequent drinkers

f.        A group rarely targeted for prevention

D.     Acknowledge 3rd variables could explain results

                                                            1.        Alc may not→ attempt, but relate to other item

a.            Time of day of attempt

b.            Place event occurs

c.             Situation surrounding event

                                                            2.      Situational events may → both acute drinking and attempt e.g., 22

a.      Relationship break up

b.      Assault

c.       Bereavement

IV.   Possible reasons for drinking on  day of attempt (Slide 18)

A.      Non-suicide related reasons (Slide 19)

                                                            1.      Context for drinking23

a.      Social: To be sociable

b.      Enhancement: To get high

c.       Coping: To forget worries

                                                            2.      Prevalence:

a.      If drink on day attempt majority drink for non-suicide reasons (67%)24

b.      Out of those who drank for non-suicide related reasons:

   ~60% believed alcohol not → attempt24

   ~40%: believed alcohol → poor judgment 24

                                                            3.      Potential reasons drinking for non-suicidal reasons ↑risk22, 25:

a.      psychological distress

b.      ↑ depressed mood and anxiety

c.       aggressiveness and impulsivity

d.      All or nothing thinking: must solve problem or kill self

e.      Alcohol myopia: Attentional short-sightedness26

   Focus on present environment such as

       a’ Why life is bad

       b’ Current pain

                  Can’t think of reasons for living such as

       a’ Family devastated

       b’ Emotional pain can’t last

B.      Suicide-related reasons (Slide 20)

                                                            1.      Context22, 25

a.      Drink to facilitate suicide attempt

b.      Drink as suicide method

                                                            2.      Prevalence

a.      Up to 33% alcohol facilitate attempt 24, 27

b.      Up to 26% used as method 28,29 

                                                            3.      Mechanisms22, 25

a.      To enable suicide by other means

   ↑courage

   Anesthetizing pain of dying

b.      As (or part of) method 22, 25

   Alcohol poisoning

   Interaction alcohol w/ medications /drugs

V.     Prevention and treatment implications (Slide 21)

A.      Why docs should know about important risk factors for suicide? (Slide 22)

                                                            1.      Provider likely contacted  in month prior to suicide

a.      ~45% met w/ primary care physician12

b.      ~20% met with mental health provider12

                                                            2.      Thus, many seek help from primary care13

B.      Alcohol use and suicide attempts co-occur

C.      Doctor’s visits unique opportunity for prevention/ intervention

D.     Docs: If patient has alcohol OR suicidal thoughts - evaluate  both (Slide 23)

                                                            1.      Screening: Other there?

                                                            2.      Monitoring: How both change over time?

                                                            3.      Prevention: If other is not there, how prevent?

                                                            4.      Treatment: How improve/change both?

E.      Doc ask about suicidal thoughts/attempts among drinkers

                                                            1.      Don’t be afraid to ask  

a.      Does not ↑ or cause suicide 30, 31 

b.      For high-risk patients: asking can ↓ suicidal thoughts & distress30

                                                            2.      Suicide queries: evidence-based tools32 (Slide 24)

a.      Use a stepwise progression:

   Ever thought about death/dying?

   Ever thought life not worth living?

   Ever thought about ending life?

   Ever attempted suicide?

   Currently thinking about ending life?

   Reasons for die and live?

b.      Avoid “faking good”

   Ask all questions

   Patient may say:

   “No” to first query

   “Yes” to later

c.       If suicidal ideation is +, ask :

   Frequency, intensity, duration of thoughts

   Existence of plan/preparatory steps

   Intent

   How much want to die

   How likely carry out thoughts/plans

F.       Docs ask ALL patients: Alc use/patterns & motives (Slide 25)

                                                            1.      Alc use/patterns: evidence-based tools

a.      Patterns: Alcohol Use Disorders Identification Test-C  (AUDIT-C)33

b.      3 Questions

   Frequency of use: When? (E.g. monthly, weekly, ~daily?)

   Never 0

   Monthly or less 1

   Two to four times a month 2

   Two to three times a week 3

   Four or more times a week 4

   # drinks consumed/typical drinking day

   None, I do not drink 0

   1 or 2: 0

   3 or 4: 1

   5 or 6: 2

   7 to 9: 3

    10 or more: 4

   Frequency of heavy episodic use (≥ 5 drinks/d [men]; ≥ 4 [female])

   Never 0

   Less than monthly 1

   Monthly 2

   Weekly 3

   Daily or almost daily 4

c.       Scoring: scale of 0-12

  Screening ≠ diagnosis → + screen requires full evaluation     

   AUD → Men > 4; Women > 3

   Sensitivity → 80-90%;  specificity → 60-70%

                                                            2.      Drinking reasons:  evidence-based tools (Slide 26)

a.      Ask why patient drinks

b.      If drinking to cope:

    1’↑ risk for suicidal thoughts 34       

   Examples include23

   To cheer up

   Helps when get depressed

   To forget worries

   Help patient find other coping strategies

   How coped in past w/out alcohol?

   Other things worked before to cheer up like:

(1)   Call friend

(2)   Walk in park

(3)   Watch comedy

                                                            3.      Docs remember: Don’t ignore  infrequent drink or non AUD

a.      Prelim. Evid.: Infrequent drinkers ↑ suicide risk while drinking21

b.      Acute alcohol may trigger suicide attempt21

G. Using clinical case  to demonstrate some of steps presented above (Slide 27)

1. Initial primary care physician evaluation-recap

                                 a.    Using evidenced based tools above

                                          1’ No suicide thoughts or past attempts

                                          2’ She drank < 1 mo; 1-2 drinks per occasion

                                          No evidence of AUD

                                 b.     Mentions relationship problems

                                 c.      View at alcohol-related risk for suicide?

                                 d.     What is missing, such as

                                         1’ How cope?

                                         2’ Reasons use alcohol?

                  2. What happened to patient? (Slide 28)

                                              a.    Boyfriend broke up with her

                                 b.    She attempted suicide

                                 c.    Brought to the ER by family and reported    

              1’ Used alcohol for coping

              Thought about suicide shortly before attempt

                     3.   Was drinking connected to attempt?

                                a.    Not enough information yet

                                b.   Could have drank early in the morning & attempt at night

                                c.    Don’t know whether they are connected

           H. Doc explore alcohol and suicide connection [case info incorporated in brackets] (Slide 29)

                    1. Goal: help prevent future alc/suicide acts

2. Consider behavior chain analysis32

                                             a.     Discuss most recent alc/suicide episode

       b.    Identify when problem started [break-up]

c.    Discuss how vulnerable to problem

                                          Physical illness [none]

                                          Not taking medications [no]

                                          Eat too little/much [skip lunch]

                                          Sleep too little/much [stayed up late]

                                          Drug use [none]

                                          Alcohol use [none prior to when problem started]

d.   Discuss prompts to alc &/or suicide at that time (Slide 30)

                                                   What thinking? [“I’ll never find anyone else”]

                                                   Neg. Mood on 1 (none) -10 (worst) scale [9]

                                                   Anger on 1 to 10 scale  [7]

                                                    What did you do? [drive to a bar]

                              e.   Identify next event/link [order 1st beer at bar]

                                                    What thinking? [“I’m going to forget about him”]

                                                    Mood on 1 (none) -10 (worst) scale [7]

                                                   Anger on 1 to 10 scale  [7]

                                                    What did you do? [drink]

    f.   Identify next event/link [order 2nd beer at bar]

                                                    What thinking? [“I feel better. I don’t need him”]

                                                    Mood on 1 (none) -10 (worst) scale [5]

                                                   Anger on 1 to 10 scale  [5]

                                                    What did you do? [order another beer]

    g.   Identify next event/link [order 4th beer at bar]

                                                    What thinking? [“I can’t live without him”]

                                                    Mood on 1 (none) -10 (worst) scale [9]

                                                   Anger on 1 to 10 scale  [7]

                                                    What did you do? [bathroom; take 100 tylenol]

                               h.    Discuss how felt after alc related suicide attempt

                                                   How feel right afterwards? [scared]

                                                   How others react? [boyfriend didn’t want to date]

                               i.   Identify “links in chain” for solutions

                                                   How prevent initial event (change how was vulnerable)

                                                               Now eat regularly-even if don’t feel like it

                                                              Now regular sleep-wake up same time

                                                     Where could have done something different 

                                                               Instead of X [bar], what could have done [walk w/friend]?

                                                               Instead of y [drink], what worked in past [relax exercise]?

3.      Process useful for:

a.      Generating specific solutions

b.      Prevent future problems

                  I. Consider Dialectical Behavior Therapy32: (Slide 31)

                                                            1.      Teaches skills  to ↓ both behaviors

                    2.   4 types of skills: ↑ ability to

a.         Focus on here-and-now

b.      Have positive interpersonal relations

c.       Regulate emotions

d.      Tolerate bad situations and negative emotions

II.      Summary (Slide 32 and 33)

A.      Relations

                                                            1.      40% drink on day of attempt

                                                            2.      Acute/chronic use: Different suicide risk

     a.  ↑ suicide risk while or soon after drinking

     b.   More important than having AUD or not

B.   Reasons for consumption

                   1. Non-suicide (common)

                   2. Drink to Cope ↑ suicide risk

C.      Prevention and Treatment Implications

                                                            1.      Assess all individuals systematically

                                                            2.      Ongoing assessment of both behaviors

                                                            3.      Explore alcohol-suicide connection
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