Substance Abuse and Suicidality

BACKGROUND

With the possible exception of tobacco, alcohol is the major harmful substance of abuse in Australia. We know that the lifetime risk for suicide in alcohol dependence is 7%, higher than for schizophrenia or affective disorder [2]. When alcoholics attempt suicide, they tend to use more lethal methods for a given level of intent [3]. Less is known about abuse of other substances, one reason being the difficulty in distinguishing between accidental and deliberate opioid overdoses; however available estimates indicate that suicide rates are substantial [4]. Additionally, fatal drug overdoses tend to occur in the context of polydrug abuse, which includes alcohol [5]. Severity of suicidal ideation in substance abusers is associated with higher rates of substance abuse [6] and the presence of other psychiatric comorbidity [7].

One likely connection between substance abuse and suicidality is through their relationship with depression. Some 40% of alcoholics have episodes of major depression; in two-thirds of these cases the depression appears to be secondary to the alcohol abuse, and will not be present otherwise [8]. One active alcoholic in twenty admitted with depression is likely to die by suicide within two years without remission from alcoholism [9]. These findings suggest that depression when combined with alcoholism is an especially powerful indicator of suicidality, and that an important way to reduce this suicidality may be to achieve remission of alcoholic drinking.

A second likely mechanism is via the disinhibiting effect of many substances, especially alcohol, allowing the breakthrough of self-destructive impulses into behaviour during intoxication. This appears to be even more important than habitual substance abuse [10]. Not uncommonly the person in emotional crisis will resort to substance abuse as a coping strategy, but of course if there is self-harm ideation this may be disastrous. Sometimes these persons are well aware that their risk of implementing self-harming behaviour will increase with intoxication, and seem to use the intoxicant to facilitate this frightening action. Others appear to have had no such conscious intentions. Such individuals may not be habitual substance abusers, and so do not have the obvious ‘suicide risk factor’ of substance abuse.

RELEVANCE TO HEALTH POLICY

These basic notions can be readily applied to public policy on suicide prevention.

The first matter to note is the existence of a large, identified, readily accessible at-risk population who are at present receiving very little focus in regard to their suicide potential. This is the clientele of our drug and alcohol services, who engage in regular contact with counsellors or methadone prescribers, and are enrolled (often repeatedly) in detoxification or drug rehabilitation programmes, many of which are residential. Commonly their presentation to such services immediately follows some personal crisis and hence they are likely to be in an emotionally vulnerable state when suicide risk is peaking. Little is known about the self-harming outcome of this population as, in general, they are not therapeutically pursued when they disengage prematurely, a common occurrence.

A related clientele is that which attends non-government refuges, half-way houses, and hostels. Staff of these organizations are even less skilled in dealing with mental illness and have even less access to psychiatric support.

These personnel may be aware of the suicidality of their clientele but are often at a loss as to how to access appropriate mental heath attention. Sadly, when they do make approaches on behalf of their clients they may be met with disinterest or encounter a discouraging barrage of administrative procedures which put the onus on them to prove that their client qualifies for mental health care, when really the need is often rather obvious from the outset. In spite of all the years of emphasizing ‘dual diagnosis’ in public health, funding in many areas remains highly compartmentalized and these streams flow down to the coal face so that ownership of the problem continues to be disputed rather than shared. And strangely, mental health professionals often feel their role in personal crises is invalidated by the absence of psychosis or major affective disorder – a dangerously limiting point of view when death is lurking. Happily there are some notable instances of effective collaboration.

Another important area, and one familiar with self-harming behaviour, is our general hospital emergency rooms. For many years experts have been drawing attention to the potential for improved recognition and intervention in substance abuse problems in emergency rooms [11], and the recommendations remain worthy of promotion. Suicide attempters in emergency rooms are more likely than other trauma cases to be intoxicated [10]. If an individual becomes dangerous to him/herself when intoxicated, whether accidentally or deliberately, this must surely be a serious substance abuse problem meriting intervention.

SUGGESTED ACTION

What might be done to address these needs? The most important factor will be the encouragement of co-ordination and co-operation at top administrative levels between Drug and Alcohol and Mental Health services. An understanding must exist that the government backs a sensible approach to this compound problem, and is serious about dealing with suicide. Planning should be informed by treatment providers and consumers from both areas of specialty. Ownership of the problem in its various guises needs to be defined.

Such co-operation may be promoted by linkage projects such as Project Gemini [12] in the Inner City of Sydney, funded by the Commonwealth Department of Human Services and Health. In this project a team of dual qualified health professionals established service linkages and educational programmes between the integrated mental health service (including the psychiatric admission unit), drug and alcohol services (including detoxification units and the methadone programme), and local non-government establishments. Other models exist and have been implemented around Australasia; it is most important that the model suit the constituency and the prevailing administrative and service philosophy, achieving culture change at a tolerable pace.

It is highly desirable that formal mechanisms be set up to screen for suicidality in clients of drug and alcohol services. This might mean for example a standard assessment at intake and perhaps periodically and at times of crisis. Concurrently education should be provided to staff to upgrade their skills allowing them to make use of the information from the screens and maintain vigilance for developing suicidality.

Complementary to the recognition of suicidality in drug and alcohol clients there must be procedures for responding. All drug and alcohol staff should receive training in basic aspects of managing suicidality. However they should not be expected to contain all the suicidality they encounter and again links with mental health services are important. Well-defined, streamlined mechanisms will be necessary for psychiatric consultation to be provided by designated individuals upon request, who can arrange for transfer of cases to mental health care when appropriate. This should occur without having to waste time cajoling or arguing the point. The drug and alcohol service should in its turn willingly provide ongoing specialist consultation or co-management for transferred cases, and agree to have them referred back if appropriate when psychiatrically stable. It would be an advantage to have designated liaison persons with dual backgrounds acting as a link between the two services.

It is perhaps in the emergency department that most support is needed to maintain a culture of suicide prevention. Patients who are ambivalent or negative about maintaining their own well-being, i.e. substance abusers and self-harmers, are abusing the sick role and are an embarrassment. They are likely to experience ‘malignant alienation’ [13]. It is important to educate staff about the need for proper prioritization of suicide risk, the appropriate place of paternalistic or coercive approaches, and the great value of timely, effective intervention. Education must be repeated frequently for medical staff, who do the initial assessments after triaging, because they are rotated rapidly through the service. Important educational points include:

In the emergency room too support is needed from specialist services, preferably integrated mental health service teams, who must be available for rapid consultation. These teams in turn need mechanisms available to them for resolution of dual diagnosis problems without procedural uncertainty or turf conflicts.

Finally, at a primary prevention level, one might be bold enough to recommend that alcoholic beverages carry a warning label along the following lines: ‘This product should not be taken when depressed. Increases suicide risk.’

CONCLUSION

In these times of interest in controlling national suicide rates, attention to the suicidal substance abuser is an obvious necessity.