Title: Alcohol Use and Suicidal Behavior in College Students

Dorian A. Lamis, PhD

Department of Psychiatry and Behavioral Sciences

Emory University School of Medicine

Alcohol Medical Scholars Program

I.        Introduction

         A. Alcohol use: common in US college students (SLIDE 2)

                1. ~75% alcohol use past year1,2,3

                        2. ~40% drink >4-5 drinks/occas past month1,2,5

                        3. 20% college students have alc-related Dx (I define later)6,7

         B. Suicidal behavior common in US college students

 1. 2nd leading cause of death8

 2. 18% ever seriously considered suicide9

 3. 8% lifetime suicide attempt9

          C. National annual costs: alcohol use and suicidal behavior

                1. Alcohol use and related Dx :  $235 billion10

                2. Suicide attempts and deaths: $58.4 billion1

          D. Clinical Case (Jane- initial visit): Is this student at risk for suicide? (SLIDE 3)           

                1. Visits primary care physician for check-up

                2. 19 yr. old female

                3. Drinking: 3 times a week; usual 3-4 drinks/occasion

4. No suicidal ideation

5. Some depressive symptoms (e.g., loss of appetite)

6. Behind with schoolwork

7. Missing classes weekly  

8. Interpersonal difficulties (e.g., relationship breakup)

          E. This lecture will cover: (SLIDE 4)

1. Definitions of alcohol use and suicidal behavior

2. How alcohol use and suicidal behavior are related

3. College student alcohol use and suicidal behavior: potential pathways

4. Clinical implications

5. Prevention implications

6. Treatment approaches

II.      Definitions (SLIDE 5)

           A. Alcohol use and AUD (SLIDE 6)

                  1. Standard drink = 10-12 g pure ethanol (beverage alcohol)12

  a. Beer: 12 oz/355 ml

  b. Wine: 4 oz/120 ml

  c. Spirits (vodka): 1.5 oz/44 ml

        2. Drinking patterns

   a. Heavy episodic (HED)13

1’.  BAC: Blood Alcohol Level (amount of alcohol in blood)

2’.  HED ≈ 0.08 BAC

3’. 4/5 drinks / within 2 hr

            3. Alcohol use disorder (AUD) (SLIDE 7)

     a. Associated with health & social problems

      b. Amer Psychiat Assn  (DSM-5) criteria (2+ in same 12 months)14

 1’. Taken in larger amounts or over longer period

                   2’. Unsuccessful efforts to ↓ use

                   3’. Large amount of time obtaining, using or recovering

                   4’. Craving or urge to use

                   5’. Failure to fulfill obligations

                   6’. Continued use despite social problems

                   7’. Important activities given up or reduced

                   8’. Use in situations physically hazardous

                   9’. Alc use despite knowledge of health problem

                  10’. Tolerance (1+ of)

                    a’.  ↑ amounts to achieve effect

                    b’.  ↓ effect at same amount

                   11.’ Withdrawal

                     a’.  Withdrawal syndromes (shakes/ insomnia/etc)

                     b’.  Develops if no alc or drink to prevent

  B. Suicidal behavior15 (SLIDE 8)

      1. Suicidal ideation: Thoughts of killing oneself

     2. Suicide attempt: Non-fatal outcome w/intent to die

     3. Suicide death: Fatal outcome

II.      Alcohol use and suicidal behavior relate (SLIDE 9)

      A. AUDs and suicidal behavior (SLIDE 10)

                1. AUDs and suicidal ideation: ↑ 4 X vs. no AUD16,17

                         2. AUDs and suicide attempts: ↑ 6 X vs. no AUD16,17

                         3. AUDs and suicide deaths: ↑ 9 X vs. Gen. Pop.18,19

                                           B. HED (4+ /5+) and:

                 1. Suicidal ideation: ↑ 2 X HED vs. no HED20

  2. Suicide attempts: 17% HED vs. 7% no HED21

  3. Suicide deaths: ~20% decedents ≥0.08 BAC22,23

III.    College student alcohol use and suicidal behavior: potential pathways

          A. First potential pathway24 (SLIDE 11)

    1. Alcohol use impulsive/aggressive behaviors25

    2. Impulsive/aggressive behaviors life strains

       a. Negative life events (e.g., work dismissal)26

       b. Interpersonal difficulties (e.g., relationship breakup)27

       c. Alcohol-related problems (e.g., physical fights)28

      3. Life strains depressive symptoms29

      4. Depressive symptoms suicidal behavior30,31

                               B. Second potential pathway32,33 (SLIDE 12)

                                    1. Depression → hopelessness

                                       2. Hopelessness → lack of connections/purpose in life

                                    3. Lack of connections/purpose in life → alcohol use

                                    4. Alcohol use → suicidal behavior

                                C. Both likely to operate (SLIDE 13)

                                       1. Primary depression confers risk for suicidal behavior

                                       2. Co-morbid alcohol use and/or AUD → additional risk

                                    3. Many other variables involved

IV.   Clinical Implications (SLIDE 14)

    A. Screening (SLIDE 15)

             1. 85% depressed and/or suicidal students not receiving help34

             2. Screening can be conducted in a variety of settings   

a.                   Throughout the school (email all students)35

b.                   For students coming for emergency care

c.  At college counseling centers

d.                   Primary care providers

e.                   From fraternities/sororities

f.  Within  athletic programs

   3. Screening tools for alcohol (SLIDE 16)

          a. Alcohol Use Disorders Identification Test  (AUDIT-C)36,37

                                                            1’. Three questions on:

                                                                       a’. Frequency of any alcohol use

                                                                       b’. Typical number of drinks

                                                                       c’. Frequency of 6+ drinks on one occasion

                                                              2’. Responses are summed

                                                              3’. Score > 5/7 / corresponds to risky drinking (HED)                                                                               

                                              4.  Screening tools for suicide risk (SLIDE 17)

            b. Beck Scale for Suicide Ideation (BSSI)38

              1’. Nineteen items (0-2) past week suicide ideation (0-38)   

              2’. Five screening items, 14 items intensity of SI

                                                                 3’. Responses are summed

                                                               4’. Score of >2 on 5-item screener = high risk39,40

                                                               5’. score on total scale = SI

V.     Prevention implications (SLIDE 18)

           A. Docs should know about suicide risk factors (SLIDE 19)

        1. Provider likely contacted in month prior to suicide

            a. ~45% suicides met w/ primary care physician41

            b. ~20% met with mental health provider

         2. Thus, many seek help from primary care: Unique opportunity  

            B. Docs: If patient has alcohol risk OR suicidal ideation - evaluate both

          1. Screening: If one risk present, screen for other

          2. Monitoring: How both change over time

          3. Prevention: If neither there, how to prevent

          4. Treatment: How to reduce/stop both behaviors

             C. Ask about suicidal ideation/attempts among student drinkers (SLIDE 20)

                1. Don’t be afraid to ask  

                            a. Does not ↑ ideation or cause suicide41

                            b. High-risk pts: asking can ↓ suicidal ideation/distress43

           2. If suicidal ideation is +, ask:

                        a. Frequency, intensity, duration of ideation

                        b. Existence of plan/preparatory steps

                        c. Intent

                                   1’. How much want to die

                                   2’. How likely carry out thoughts/plans

                                              d. Is EMERGENCY if: (SLIDE 21)

                                                              1’. Recent social stressors and/or loss of resources

                                                         2’. Severe psychiatric symptoms (e.g., psychosis)

                                                         3’. Hopeless

                                                              4’. Has plan

                                                              5’. Has available lethal means to carry out plan

                                              e. If emergency must take to MH worker or ED

         D. Using clinical case to demonstrate some of steps presented above

               1. Initial PCP evaluation- Jane revisited (SLIDE 22)

                                               a. Using evidenced-based tools above

                                                               1’. No suicidal ideation (BSSI = 0)

                                                               2’. Drinks 3 times/week; 4 drinks/occas (AUDIT-C = 4)

                                                               3’. No evidence of AUD

                                               b. Mentions relationship problems

                                               c. Reports depressive symptoms (↓ energy/motivation)

                                      2. What happened to Jane (follow-up visit)?  (SLIDE 23)

                                                             a. Drinks more and more often (AUDIT-C = 7)

                                                          b. Failing two classes (may lose academic scholarship)

                                                          c. Boyfriend broke up with her

                                                        d. Feels hopeless

                                              e. Seriously considering suicide (BSSI screen =3; BSSI total =16)

VI.   Treatment approaches (SLIDE 24)

                                A. Motivational Interviewing (MI)44,45 – Originally for alcohol use (SLIDE 25)

                                          1. Therapeutic relationship collaborative

                                          2. Focused on pts thoughts/feelings

                                          3. Practitioner guides talk

                                          4. Motivate pt to change unhealthy behaviors (↓ alc)

                                          5. Build motivation and commitment to live

                                          6. Explore ambivalence about change (pros vs. cons)

                                          7. Guide pt towards change      

                                B. Cognitive Behavior Therapy for Suicide Prevention (CBT-SP)46,47(SLIDE 26)

                                                     1. Initial phase (sessions 1-3)

                               a. Education

                                      1’. Provide information about:

                                                a’.  Nature of suicidal behavior (e.g., risk factors)

                                                b’. How alcohol ↑ depression/suicidal ideation

                                                c’. Restricting lethal means (e.g., remove guns)      

                                b. Behavior chain analysis: Aware of circumstances → SI

                                       1’. Individual in environment (e.g., triggering event)

                                     2’. Reviews step-by-step sequence of events→ SI

                             c. Collaborative safety planning/coping card (SLIDE 27)

                                      1’. Create list of coping strategies

                                      2’. List sources of support if SI thought to re-occur               

                        d. Reasons for living (RFL)

                                       1’. Identify personal reasons for staying alive

                                       2’. Hope kit: photos/trinkets as reminders of RFLs      

                                2. Middle phase (sessions 4-9) (SLIDE 28)

                                             a. Skills modules

                                                         1’. Behavioral activation – ↑ pleasurable activities                                                                        2’. Mood monitoring – track daily moods in diary         

                                        3’. Emotion regulation –control emotion and mood

                                                     a’. Do something enjoyable to improve mood

                                                     b’. Making yourself anxious by worrying

                                                            4’. Cognitive restructuring (SLIDE 29)

                                                                         a’. Identify irrational thoughts (“all is bad”)

                                                                         b’. Alt thoughts (“some bad, others good”)                                                           5’. Assertiveness skills

                                                                          a’. How to effectively express point of view                                                                     b’. While respecting others’ rights/beliefs

                                3. End phase (sessions 10-12) (SLIDE 30)

                                                 a. Relapse prevention

                                                              1’. Review of suicidal crisis using skills

                                                               2’. Debriefing and follow-up

                                           4. Continuation phase (6 biweekly sessions)

                                                           a. Review skills

                                                           b. Discuss reactions to treatment and termination

                          C. Integrated CBT for co-occur alcohol use & suicidal behavior48-50(SLIDE 31)

                                           1. Guided by social cognitive learning theory (SCLT)51

                                                        a’. SCLT: Learning of social behaviors and core beliefs →               

                                                             MH problems

                                                        b’. Assessment of alcohol use and suicidal behavior

                                                        c’. MI to improve motivation and readiness to tx

                                                        d’. Develop self confidence/esteem

                                                        e’. ↓ maladaptive cog/beh -> alc use and SB (SLIDE 32)

                                                        f’. Improve communication skills

                                                        g’. Enhance problem solving

                                                        h’. Improve emotion regulation

                        D. Dialectical Behavior Therapy (DBT)52 (SLIDE 33)

                                      1. Skills to ↓ both alcohol and suicidal behaviors

                                                 a. Teaches 4 types of skills: ↑ ability to

                                                                      1’. Focus on here-and-now

                                                                           2’. Have positive interpersonal relations

                                                                           3’. Regulate emotions

                                                                           4’. Tolerate bad situations and negative emotions

VII. Conclusions/Summary (SLIDE 34)

                         A. College student alcohol use and suicidal behavior are common and co-occur

            B. ↑ Systematic screening needed

            C. Ongoing assessment of both behaviors

            D. Identify/address alcohol use–suicide risk link (eg., interpersonal difficulties)

            E. Addressing both behaviors most effective

























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