Assess routinely for suicide risk

The January/February 2009 issue of the Substance Abuse and Mental Health Services Administration's SAMHSA News announced the publication of a white paper on the relationship among substance abuse, untreated mental illness, and suicide.1 As a dual certified mental health and substance abuse clinician, I know firsthand the deadly interrelatedness of these three factors.

During my employment at an Arizona Indian Health Service hospital and with a tribal organization in western Alaska, I witnessed time and again the impact that substance misuse (primarily of alcohol) and untreated mental distress had on suicidal ideation, suicide attempts, and completions. Despite the fact that the native people themselves had placed prohibitions on alcohol availability within their own communities, alcohol was frequently present when intervening with self-harming patients in the emergency room, at their homes, or in the office.

I applaud the efforts of SAMHSA, one of our most trusted authorities, in refocusing our attention on this deadly relationship so that we in the substance abuse and mental health fields can more effectively work to alleviate suffering and prevent suicide. I fully believe that if workers can incorporate this vital information into routine practice, it will have a transforming effect on both fields.

SAMHSA's choosing a white paper as the format in which to present its findings speaks to the fact that the paper's topic has not yet been fully translated into common practice. This is difficult to understand given the multitude of sources reporting the relationship among substance use, untreated mental illness, and increased suicide risk. Three years ago after daily practice illuminated the interconnectedness of the factors in my own work, I gathered research for a proposal to increase the number of self-help sobriety groups in native Alaskan villages in an effort to reduce alcohol use and suicidality.2 I gathered much of my research from well-recognized authorities such as the National Institute of Mental Health (NIMH), the American Journal of Public Health, Suicide Prevention Action Network USA, Suicide Prevention Resource Center, the Department of Health and Human Services (HHS), and the National Institute on Alcohol Abuse and Alcoholism (NIAAA). Working at the time with the Alaska Native people, I targeted this group for my proposal.

However, native people are by no means the only vulnerable population at higher risk for suicide. Other particularly high-risk groups include white males over age 753; gay, lesbian, bisexual, and transgender individuals; individuals with borderline personality disorder or schizophrenia; white males ages 24 to 55; and the incarcerated.4

Important statistics

Here are a few salient statistics regarding suicide, mental illness, and substance use:

• One life is lost to suicide approximately every 16 minutes.5

• For the 33,000 lives lost by suicide in the United States annually, there are an estimated 1 million suicide attempts.5

• Suicide is the third leading cause of death for those between ages 15 and 24, the fourth leading cause of death for those ages 25 to 44, and the eighth leading cause of death for those ages 45 to 64. For those 65 to 74, there are 12.6 deaths by suicide per 100,000. For those 75 and older, the death rate increases to 16.9 per 100,000.6

• Suicide rates among American Indian and Alaska Native teens and young adults are twice that of the national average.7

• 90 percent of those who attempt suicide have a mental illness and/or substance use disorder.7

• Substance use is thought to be involved in up to 50 percent of all suicides.3

And these rates have remained essentially stable for 50 years.7

Responsibility for assessment

Throughout my career, I have seen the responsibility of suicide assessment fall primarily to mental health workers. Suicidality is most closely associated with hopelessness and depression. Hopelessness is found to be a component of a variety of mood disorders, including major depressive disorder, dysthymic disorder, the depressive phase of bipolar disorder, and adjustment disorder with depressed mood. An individual misusing substances is often found to be experiencing a concomitant negative impact on his/her mental health, which frequently includes depressive symptomology. Drugs and alcohol are often used as a means of “self-medication” by those in psychological distress.

Screening for suicide risk at each and every intake offers one of the best ways in which we can prevent suicide.

As the fields of mental health and chemical dependency work more closely together, co-occurring disorders are recognized more commonly as the rule rather than the exception, and there is ample overlap in the disorders' etiology and outcomes. Both mental illness and alcoholism are recognized as brain diseases. Individuals with mental illness and substance abuse disorders are frequently treated with medications that affect the brain's neurotransmitters. Alcohol interacts with and alters the brain's neurotransmitters to increase poor decision making and risk-taking behavior, both of which lead to increased morbidity and mortality. Specifically, the four neurotransmitters alcohol interacts with in the brain are met-encephalin (responsible for pain reduction), dopamine (associated with pleasure), serotonin (associated with feelings of well-being), and gamma amino butyric acid (associated with inhibition).8 Serotonin and dopamine in particular are the two neurotransmitters that psychopharmacology aims to increase the presence of in cases of depression.

The self-medicating effect an individual seeks when drinking is one of relaxation and well-being as specific neurotransmitters are increased. Continued drinking causes these same brain chemicals to become suppressed.9 Despite this, the substance-using behavior is repeated and perpetuated by the addictive nature of the substance itself. The overlap and overlay of symptomology and behavior present in individuals with mental illness and/or substance misuse points to the equal responsibility of workers in both the mental health and chemical dependency fields to assess routinely for suicidality.

Recognition within the chemical dependency and mental health fields regarding the interconnectedness of substance misuse and mental distress is increasing. As the two fields become more integrated, it is curious to think they were ever separate in the first place. The life stressors that overwhelm an individual's natural coping skill level and personal resiliency that lead to mental illness and/or substance abuse/dependence are identical. Within the mental health field, the stress diathesis model states that individuals have vulnerabilities that lie dormant until stimulated by environmental or biological stressors.10 The DSM-IV-TR devotes one of its five axes to contributing psychosocial and environmental factors to diagnosable mental illness.11 Likewise, the American Society of Addiction Medicine (ASAM) takes into account the impact of life stressors when formulating decisions for appropriate level of treatment, and designates one of its six dimensions to emotional, behavioral, and cognitive conditions and complications that affect treatment potential.12 It is important that workers in both chemical dependency and mental health more fully recognize that use of alcohol by an individual under stress can lead to thoughts of self-harm (as well as harm to others) because of alcohol's depressive and disinhibiting properties.

Efforts in prevention

It is widely reported that suicide is preventable-indeed, this is addressed in Goal 1 of the National Strategy for Suicide Prevention (NSSP).4 The NSSP, a comprehensive guide for individuals and organizations seeking to do more to prevent the tragedy of suicide, outlines 11 goals and objectives for action to prevent suicide. Goal 7 is to “develop and promote effective clinical and professional practices.” This is surely what both the chemical dependency and mental health fields strive constantly to do.

I am convicted in my belief that screening for suicide risk at each and every substance abuse and mental health intake offers one of the best ways in which we can prevent suicide. Eight out of 10 individuals thinking of self-harm give some sort of indication of their intentions3, and programs aimed at suicide prevention emphasize that asking directly if an individual is thinking of self-harm opens the door to intervention and prevention.13

Outreach to those not yet involved in substance abuse or mental health treatment increases prevention possibilities and coincides with Goal 8 of the NSSP (“increased access to and community linkages with mental health and substance abuse services”). In Alaska, the addition of just two questions on the standard clinic intake (“Over the last couple of weeks, have you felt sad none of the time, some of the time, much of the time, all of the time?” and “Over the last couple of weeks, have you had any thoughts or plans of wanting to hurt yourself?”) led to mental health and substance abuse regular and emergency services, and, I believe, suicide prevention.14 The posting of the National Suicide Prevention Lifeline toll-free number on Alaska village community bulletin boards also increased outreach and brought services aimed at reducing suicide.

In addition, these strategies cost very little to implement. While suicide costs the U.S. more than $11.5 billion annually in lost income7, the cost of modifying a standard form or posting flyers is pennies on the dollar.

While actions such as last year's passage of comprehensive parity legislation represent a great step forward in terms of access to services, there is so much work left to do. I recommend reading SAMHSA's white paper as well as the National Strategy for Suicide Prevention. SAMHSA's recently published Treatment Improvement Protocol 50, Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment, is another helpful resource offering best practice guidelines for front-line counselors as well as clinical supervisors.15 Exemplary works such as these inspire us to create new ways to serve the client populations to which we are committed.

I look forward to the day when the chemical dependency and mental health fields come together once and for all, lower their individual flags, design a new flag under which we can all stand united, and march forward together in an effort to help our clients learn to better help themselves. Perhaps then, there will be less suffering overall and fewer deaths by suicide, as well as fewer reports having to be written and rewritten.
Julie A. Niven, LCSW, DCSW, MAC

References

1. Substance Abuse and Mental Health Services Administration. Suicide prevention: white paper examines relationship between substance abuse and suicide. SAMHSA News 2009; 17:8-9.
2. Niven JA. Sobriety-focused self-help groups in Alaska's villages can improve quality of life in the Alaska native population. The IHS Prim Care Prov 2007; 32:75-6.
3. Mental Health America. Fact Sheet: Suicide. Available at https://www.mentalhealthamerica.net/go/suicide.
4. United States Department of Health and Human Services. National Strategy for Suicide Prevention: Goals and Objectives for Action. Rockville Md.:U.S. Department of Health and Human Services, Public Health Service; 2001.
5. American Foundation for Suicide Prevention. Facts and Figures: National Statistics. Available at https://www.afsp.org/index.cfm?fuseaction=home.viewpageandpage_id=050FEA9F-B064-4092-B1135C3A70DE1FDA.
6. National Center for Health Statistics. Health, United States. Hyattsville Md.:Centers for Disease Control and Prevention; 2008.
7. United States Department of Health and Human Services. Substance abuse and suicide prevention: evidence and implications. A white paper. Rockville Md.:Substance Abuse and Mental Health Services Administration; 2008.
8. Inaba DS, Cohen WE. Uppers, Downers, All Arounders, 4 th ed. Ashland Ore.:CNS Publications; 2000.
9. Weed CM. The Biology of Addiction. Available at https://www.alcoholanswers.org/alcohol-education/biology-of-addiction.cfm.
10. Kaplan HI, Sadock BJ, Grebb JA. Kaplan and Sadock's Synopsis of Psychiatry: Behavioral Sciences, Clinical Psychiatry, 7 th ed. Baltimore:Williams and Wilkins; 1994.
11. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Text Revision. Washington D.C.:American Psychiatric Publishing; 2000.
12. American Society of Addiction Medicine. ASAM PCC-2R: ASAM Patient Placement Criteria for the Treatment of Substance Related Disorders. Chevy Chase Md.:American Society of Addiction Medicine; 2001.
13. Living Works. Suicide Intervention Handbook. Calgary Alberta Canada:Living Works; 1994.
14. Niven JA. Screening for depression and thoughts of suicide: a tool for use in Alaska's village clinics. Am Indian Alsk Native Ment Health Res: J Nat Center 2007; 14:16-28.
15. Substance Abuse and Mental Health Services Administration. Treatment Improvement Protocol (TIP) 50: Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment. Available at https://ncadistore.samhsa.gov/catalog/productDetails.aspx?ProductID=18118.