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Dying for a Drink or Drug: Suicide and Addiction

Dying for a Drink or Drug: Suicide and Addiction. Richard Ries MD rries@u.washington.edu Harborview Medical Center and the University of Washington Seattle, Washington. Some Facts about Suicide:. 30,000 die by suicide in USA each year More die by suicide than homicide (1.7 times more)

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Dying for a Drink or Drug: Suicide and Addiction

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  1. Dying for a Drink or Drug: Suicide and Addiction Richard Ries MD rries@u.washington.edu Harborview Medical Center and the University of Washington Seattle, Washington R.Ries Addiction and Suicide

  2. Some Facts about Suicide: • 30,000 die by suicide in USA each year • More die by suicide than homicide (1.7 times more) • Third leading cause of death in those 15-24 ….more than cancer, AIDS, heart, and lung disease combined • Males die 4x more often, but females make more attempts • 60% die by firearm CDC web site R.Ries Addiction and Suicide

  3. Facts about Suicide: • 500,000 ER visits for attempts in 1997 • Four times as many US citizens died by suicide during the Viet Nam War period than died as soldiers. • Rates increase with age ( as do other causes of death) • Often Drug/Alcohol related >…IMPLICATIONS…. CDC web site R.Ries Addiction and Suicide

  4. Is Suicide Primarily: “Mental Health Territory” • Lifetime Suicide risk for Schizophrenic, Affective and Addiction Disorders: • Method: review of 83 mortality studies: • Schizophrenia…………4% • Affective Disorders……6% • Addiction Disorders…...7% Inskip HM: Br J Psych 1998 R.Ries Addiction and Suicide

  5. Should Suicide be Primarily “Mental Health Territory” • Alcohol strongest predictor of completed suicide over 5-10 years after attempt, OR= 5.18…vs. demog or psych disorders ( Beck J Stud Alc 1989) • 40-60% of completed suicides across USA/Europe are alcohol/drug affected (Editorial: Dying for a Drink: Brit Med J. 2001) • Higher suicide rates (+8%) in 18 vs. 21yo legal drinking age states for those ages (Birckmayer J: Am J Pub Health 1999) R.Ries Addiction and Suicide

  6. What do we know about Suicide in Alcoholic Populations • 4.5% of alcoholics attempted suicide within 5 years of DX • ( age 40.. n=1,237) • 0.8% in non-alcoholic matched comparison group • ( age 42..n=2,000)… • p< .001………..7X increased risk Preuss/Schuckit Am J Psych 03 R.Ries Addiction and Suicide

  7. What Predicted Suicide Attempts in Alcoholics (n=1,237) over 5 years? • Rate = 4.5% attempted suicide • Prior attempts • Earlier onset and more severe dependence. Other drug dependence • Separated or divorced • More likely to have had treatment ( more severe) • More Panic • More Substance Induced Psych Disorder ( but not Maj dep, etc.) Preuss/Schuckit et al Am J Psych 03 R.Ries Addiction and Suicide

  8. Comparison of Frequency of Risk Factors in White Male Alcoholics Who Committed Suicide and Living Alcoholic Controls from Epidemiologic Catchment Area Study R.Ries Addiction and Suicide

  9. Substance Induced Depression: Severity/Dangerousness • Henriksson, et al (1993)- 43% of completed suicides had alcohol dependence. 48% of these were also depressed. 42% had a personality disorder. • Elliot, et al (1996)- patients with medically severe suicide attempts had a statistically higher prevalence or substance-induced mood disorder. R.Ries Addiction and Suicide

  10. HARBORVIEW MEDICAL CENTERINPATIENT DATA BASE 1996-2003SUICIDE STUDY (Ries , Russo, Roy-Byrne unpub) R.Ries Addiction and Suicide

  11. RELATIONSHIP OF ALCOHOL & DRUG PROBLEMSTO SEVERE SUICIDALITY (n=12,196) Percent With Severe Suicide Rating ALCOHOL OR DRUG PROBLEMS ODDS adjusted for age & gender Walds = 235.41 p < .001 R.Ries Addiction and Suicide Ries & Russo, 2003

  12. RELATIONSHIP OF SUICIDE TO PSYCHIATRIC DIAGNOSIS AND SUBSTANCE DEPENDENCE Percent With Severe Suicide Rating R.Ries Addiction and Suicide Ries & Russo, 2003

  13. In an acute suicidal inpatient with mood lability, impulsivity and substance use… is it: Major Depression, Dysphoric Mania or Substance Induced Mood? • Can Clinicians tell the difference? • Can Researchers tell the difference? • What is Comparative Lethality? • What are the Managed care implications? (Psych Dx vs. Alchol/Drg related Dx as primary … e.g., Substance Induced Depression/Anxiety, • Payment (Lots)!....Length of Stay ( 2 vs. 6-8 days) • Would the treatment approaches differ? • YES R.Ries Addiction and Suicide

  14. In “Mental Health” settings: • Substance Induced Suicidal pts often get dx’d with “Major Depression, Depression NOS, Bipolar Depression, Bipolar II etc” and started on meds….. • Because: • It justifies managed care review ( payment) • It’s what most Psychiatrists know how to do • Often saying “meds shouldn’t hurt, but might help” ….even if the doctor thinks SIMD most likely R.Ries Addiction and Suicide

  15. However : • The pt now carries dx of “major depression” or Bipolar II etc, with recent suicide attempt….(and soon may be on the way to SSI MH disability, with funds to use for Alc/Drugs) • At Discharge, this usually means referral to either MHC or Primary Care prescriber….neither of which offers what SIMD pts really NEED… • Which is Primary Addiction Treatment, at a site which can tolerate such recently suicidal patients and provide meds if needed R.Ries Addiction and Suicide

  16. Implications of SIMD Misdiagnosis • Clinical databases that don’t include SIMD • Overestimation of Psychiatric Disorders, such as Bipolar …both clinically and in Research studies if using non-sophisticated instruments • Misdirected treatment of 1’ addiction disorders as Major depression etc • Unnecessary, expensive, and potentially medically risky medications • Khan found no affect of antidepressants over placebo in decreasing suicide symptoms ( FDA database 2002) • Likely more suicide/suicide attempts if not sober R.Ries Addiction and Suicide

  17. Can addiction treatment affect suicidality? Cohort suicide attempts year prior year after Adults > 25 yo (n=3524) 23%...........................4% 18-24 yo (N=651) 28%...........................4% Adoles (n=236) 23%...........................7% Karageorge: National Treatment Improvement Evaluation study 2001 R.Ries Addiction and Suicide

  18. So what does the MH system need to do? • All acute psych units need to be Dual DX units, i.e., have a serious degree of integrated substance intervention. • Greatly increased Addictions training in psychiatrists and other staff. • Remove the Length of Stay, Payment and Managed Care policies which drive misdiagnosis and mistreatment. • Researchers need to use instruments like the PRISM ( Hasin D, et al.) and factor substance use issues into analyses of suicide and other problem behaviors • Develop DBT programs for high frequency Borderline attempters R.Ries Addiction and Suicide

  19. So what do Addiction Systems Need to do? • Acknowledge that about half of their pts have been or are suicidal and train staff accordingly. • Hold on to their suicidal patients • Know that a protective suicide intervention is sobriety, but focused suicide prevention methods are needed…Better research in this area is needed. • Provide integrated medications management on site, if MH dx is blatant and interferes with Addiction Treatment, • However less than a quarter of the addictions programs in the USA have onsite prescribers, and less than half of those are psychiatrists R.Ries Addiction and Suicide

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