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 <Slide 16>

            1.   Depressive symptoms are common in heavy drinking

                  a.   80% patients with alc dependence report depressive sxs lifetime

                  b.   Sustained heavy alcohol use can induce depressive symptoms

            2.   Syndromes seen in context of heavy drinking<Slide 17>

                  a.   “Independent” MDD

                        i.    Predates alc dependence dx or occurring in times of sustained abstinence

                        ii.    More likely to have family history of MDD than alcohol-induced

                        iii.   15% of alc dependence patients

                  b.   Alcohol-induced MDD <Slide 18>

                        i.    Temporary sxs associated with alcohol use

                        ii.    Typically resolve in ~ 4 weeks

                        iii.   Do not occur during periods of sustained abstinence

                        iv.   Less likely to have family history of MDD

                        v.   26% of alc dependence patients  <Slide 19>

            3.   Depression + alc dependence =  ­ suicide rate <Slide 20>

                  a.   Independent depression ↑ suicide attempt rate vs. alc induced 15

                  b.   Suicide risk effects amplified by increasing age

                  c.   Depression and/or alc dependence make up ~65% of all suicides8

            4.  Alcohol use disorders, suicide and depression are interrelated <Slide 21>

IV. How to screen and identify patients “at risk” (alc problems + suicide) <Slide 22>

      A.  First principle – ASK everyone systematically <Slide 23>

            1.   Physician ability to ID alcohol, MDD, & suicide related problems is poor

                  a.   <25% patients routinely screened for alcohol use16

                  b.   ~40% patients with depression missed by primary care17

                  c.   ~ 35% of patients with depression asked about suicide18

                  d.   MDs report discomfort with asking, miss obvious clinical patterns

            2.   Patients expect to be <Slide 24>

                  a.   Asked about alcohol use/emotional problems

                  b.   Provided guidance about use and risky behaviors

                  c.   Judge MD on attention to above

      B.   Ask all patients about alc problems using evidence-based screening tools <Slide 25>

            1.  Screening ≠ diagnosis → positive screen requires full evaluation

            2.   CAGE <Slide 26>

                  a.   Four questions: cut down, annoyed, guilt, eye-opener19 (see attached)

                  b.   > Two affirmative answers = positive test

                  c.   Sensitivity → 50-80%; specificity → ~ 80%

                  d.  Doesn’t screen for hazardous drinking 

            3.   Alcohol Use Disorders Identification Test (AUDIT) <Slide 27>

                  a.   Ten-item questionnaire developed by W.H.O.20(see attached)

                  c.   Score of > 8 = positive test for hazardous drinking/ ↑alc. dx

                  d.   Sensitivity → 50-90%;  specificity → 80%

            4.   AUDIT-C

                  a.   3-question survey using the consumption ?s from AUDIT20 (see attached)

                  b.   Equal in sensitivity/specificity to full AUDIT

                  c.  Positive score for identifying hazardous drinking → Men > 4; Women > 3

      B.   Physical examination <Slide 28>

            1.   Hypertension: ł 3 drinks/day with ­ blood pressure 

            2.   Hepatosplenomegaly:  ­ in liver or spleen size

            3.   Peripheral neuropathy:  15% of those with alc dependence

      C.        State markers of heavy alc use can help21 <Slide 29>

            1.   Definition: blood tests which temporarily ∆ if drink 5+ drinks/d X 5+days

            2.   Gamma-glutamyl transferase (GGT) >35 µ/L

                  a.   Involved in amino acid transport

                  b.   Sensitivity:  ~ 70% men/50% women; specificity ~70% both sexes

            3.   Carbohydrate-deficient transferrin (CDT) > 2.5%22

                  a.   Heavy drinking association over extended periods

                  b.   Change in proportion of transferrin

                  c.   Sensitivity:  30-75%:  M > W; specificity:  up to 90%

                  d.   Interpretation complicated by iron deficiency

            4.   CBC w/mean corpuscular volume

                  a.   ­ alcohol use affects RBC production

                  b.   MCV ­ = > 92

                  c.   unknown sensitivity and specificity

            5.   Aspartate transaminase (AST)

                  a.   Liver function test → Multiple reasons for ↑ beyond alc

                  b.   Sensitivity with heavy drinking 25-45%; specificity as high as 90%

                  c.   Combined with alanine transaminase (ALT) testing for ratio

                  d.   AST/ALT ratio > 2: ↑ probability alc hepatitis23 (*invalid → values > 400)

      D.  Ask patients with positive alc problem screening about depression<Slide 30>

            1.   Two question depression screening (in the past month)24

                  a.   How often have you been bothered by feeling down, depressed, or hopeless?

                  b.   How often have you been bothered by little interest/pleasure in doing things?

                  c.   > 1 affirmative answer = positive test

            2.   Sensitivity: 96%; specificity: 57%

            3.   Screening ≠ diagnosis → positive screen requires full evaluation                  

V.  How to manage alc patients identified “at risk” (at risk = screen positive for alc) <Slide 31>

      A. Identify heavy drinking/alc dependence using diagnostic criteria <Slide32 >

      B.   Interview and define presence of MDD in pts with alc dependence <Slide 33>

            1.   Timeline interview for presence of depressive symptoms

                  a.   Carefully assess presence of MDD sxs during lifetime

                  b.   Are sxs present or absent during sustained abstinence?

                  c.   Family history of depression? (↑likelihood of independent)

            2.   Important to distinguish alcohol-induced from independent for rx reasons

                  a.   Alc-induced depressions markedly improve with 2-4 weeks abstinence                                     b.      Independent MDD require six to nine months of antidepressant rx               

      C. Evidence-based treatment of underlying alc disorders <Slide 34>

            1.   Motivational interviewing 25

                  a.   Emphasize change

                  b.   Discuss patients resistance to change

                  c.   Focus on patient's perspective

                  d.   Encourage change acceptable to patient

            2.   Cognitive behavioral therapy (CBT) for alc dependence

                  a.   Help patient change view of role in drinking

                  b.   Help change behaviors to ↑ sobriety

                        i.    Recognize and avoid risky situations

                        ii.    Get sober social network                                       

            3.   Medications for alc dependence (all used with psychosocial support treatments)

                  a.   Disulfiram (Antabuse): sensitizing agent to alcohol

                        i.    Inhibits alcohol dehydrogenase → ↑ blood acetaldehyde levels

                        ii.    ↑ Acetaldehyde levels → reaction: nausea/vomiting/blood pressure ∆s

                        iii.   Requires monitoring of administration, questionable efficacy

                        iv.   Medication interactions

                        v.  Dosing: 250 mg/day

                  b.   Naltrexone (Revia): opioid antagonist

                        i.    Decrease craving for/pleasurable response to alc use

                        ii.    Nausea, hepatotoxicity

                        iii.   Conflicting efficacy data

                        iv.   Dosing: 50 – 100 mg/day

                  c.   Acamprosate (Campral): glutamate receptor modulator

                        i.    Derivative of taurine (amino acid), primarily renally excreted

                        ii.    Alleviates physiological/psychological distress of abstinence

                        iii.   Dosing: ~ 2 gms/day (666 mg tid)

      D.  Perform suicide risk assessment (SAFE-T attached) <Slide 35>

            1.   Assess risk factors which ↑ likelihood of suicide-related behaviors

                  a.   Access to firearms or other lethal means

                  b.   Other psychiatric diagnoses (e.g. Panic Disorder, Personality Disorders)

                  c.   Symptoms which increase risk: agitation/anxiety, hallucinations, ↓ sleep

                  d.   Family history of suicide?

                  e.  Past history of suicide attempt(s)? Number, sought help, lethality

            2.  Assess protective factors which ↓ risk of suicide-related behaviors

                  a.   Internal: positive coping with stress, religious beliefs, frustration tolerance

                  b.   External: responsibility to family, social supports, + therapeutic relationships

            3.   Inquire about suicide using stepwise progression <Slide 36>

                  a.   Have you had feelings of hopelessness?  Can’t go on?  No future?

                  b.   Thoughts of death?  Feeling better off dead?

                  c.   Thoughts of suicide?  How often?  How intense? How long have they lasted?

                  d.   Planning for suicide:  Specific plan?  Obtaining means?  Rehearsal?

                  e.   Suicidal intent → active desire to hurt yourself now?

            4.   Define level of risk/care required based on clinical judgment <Slide 37>

                  a.   Low risk = no SI, no plan, no intent, no behavior → outpt f/u or consultation

                  b.   Moderate = SI +/- plan; no intent/behavior→ urgent referral to psychiatry/ ER

                  c.   High = thoughts/plan/intent/status post attempt/agitation → hospitalization

            5.   Document risk assessment rationale, level of care & treatment plan to ↓ risk

                  a.   Removal of firearms

                  b.   Contact with family

            6.   Initial assessment and management summary

                  a.   + screen → fuller assessment guided by disorder criteria

                  b.  Define MDD in pts with alc use disorder

                  c.  Rx underlying disorder w/evidence-based treatments

                  d.   Perform suicide risk assessment

VI. Summary <Slide 38>

      A.  Definitions: alc, dep, and suicide related-behaviors

      B.   Relationships of alc, dep, and suicide related behavior?

      C.  Screen and identify

      D.  Initially assess and manage




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