Suicidal Behavior and Adolescent Substance Use/Abuse

Oscar Bukstein, MD, MPHMedical Director

Disclosure

• Royalties from Routledge Press

Objectives/Agenda

• What About Suicide and Substance use disorders (SUDs)?–Nature of relationship

• Screening, assessment• Safety planning• Treatment

And where did you learn all this, Dr. Bukstein?

• Service for Teens at Risk (STAR Center)University of Pittsburgh Medical CenterWestern Psychiatric institute and Clinic

Dr. David BrentDr. Mary Margaret Kerr

Why is it important to assess suicidal risk and behavior?

• Suicide is the 3rd leading cause of death in adolescents

• Suicide attempts are one of the most common causes for psychiatric hospital admission in this age group.

• Suicidal thoughts and actions often pre-sage subsequent suicide attempts and completions

• Adolescents with SUDs have many suicide risk factors and have a higher suicide risk

Since 1960…..

• Rapid increase in adolescent drug use• 300% increase in suicidal behavior

–Increase between 1960-1990• Attributable to drug and alcohol

problems

Morbidity & Mortality in AdolescenceMorbidity & Mortality in Adolescence

Primary sources of death/disability are related to problems with control of behavior and emotion

• Accidents, suicide, homicide, depression, alcohol & substance use, violence, reckless behaviors, eating disorders, risky sexual behaviors…

• Risk-taking, sensation-seeking, and erratic (emotionally-influenced) behavior

• Onset of problems with later health consequences

Fundamental Imbalance in Puberty

• Rapid physical, endocrine, and social changes that create early affective motivations and challenges

• Gradual, later development of affect regulation and maturation of cognitive/self-control skills

Emotional CapacityPubertal drives and emotions; sensation seeking; risk taking; sensitivity to rewards, low self control

Cognitive CapacityPlanning; logic; reasoning, inhibitory control; problem-solving skills; capacity for understanding long-term consequences of behavior

The Adolescent BrainThe Adolescent Brain

Particularly vulnerable to external inputs:• Environmental exposures• Psychosocial stressors• Drug and alcohol use• Protective factors

Prefrontal cortex not fully developed until early adulthood• Unique stage of change in metabolism, pruning, and

increased efficiency in prefrontal functionEmotional centers (limbic) without checks and balances

• Greater sensitivity to rewards, less inhibition• Seek altered states of consciousness

Effects are longstanding

Regulatory neural circuitry b/t prefrontal cortex and limbic system vulnerable to:• genetic defects• developmental delays• injury• metabolic errors• stress and adversity• drug and alcohol use

Breakdown in Brain’s Regulatory System May Breakdown in Brain’s Regulatory System May Heighten RiskHeighten Risk

Focal Point: Prefrontal Deficits

• Inability to accurately interpret social cues • Permits negative emotions to dominate• Heightened sensitivity to rewards (immediate)• Impulsivity and Inattention• Insensitivity to Consequence

* Doesn’t fully connect until after adolescence!!!

Substance Use and Decision-Making

• Presumably substance use involves poor decision making• Decision-making is determined by the interaction of higher

level brain processes – Executive Functions– Controlled largely by Pre Frontal Cortex (PFC)

• With lower level centers– Limbic system - amygdala, hippocampus– Nucleus Acumbens

What about Pre-existing “Brain” Problems

• PFC/Executive Functioning deficits: ADHD – Increased prevalence in adolescents with SUDs/AUDs (up

to 50%)– ADHD as SUD risk factor?

• Conduct problems (up to 80%)– Definitely as risk factor

• Internalizing problems (more than half)– Depression, , irritability, and anxiety

• Genetic Origin?

Confluence of Risk Factors

Suicide in 23 adolescent suicides compared to 12 community controls with a lifetime history of substance abuse•Suicides were more likely to be active substance abusers•Have comorbid major depression,•Suicidal ideation within the past week•A family history of depression and substance abuse•Legal problems •Presence of lethal weapons in the home

•Bukstein et al., 2003

Suicide and SUDs in Adolescents

• Adolescent substance users have more than a 2.5-fold increase in risk for suicidal behaviors compared to non-drug using adolescents (SAMHSA, 2002).

• Combination of poor impulse control, stressful life events, suicidal behavior, and substance use may interact to amplify the likelihood of negative consequences that occur with these behaviors (Bridge et al. 2006; Dalton et al. 2005; Putnins, 1995).

Impulse Control, SUDs, and Suicide

• Impulse control as a risk factor for SUDs• Impulse control as a risk factor for

suicide

Stressful Life Events

• Risk factor for suicide– Parental separation, social isolation; poor family

communication, family dysfunction; relationship break-ups, conflicts with peers or parents; victimization by peers; low social support, as well as relationship strain due to parental SUD and other parental psychopathology

• Risk factor for SUDs– See above

Acute Pharmacologic Effects of drug/aclohol Intoxication

• Impair judgment• Lower inhibitions• Worsen impulse control• Affect specific neurotransmitter systems• Chronic neurocogntive effects

• Mann et al., 2003

SUD-Related Consequences

• Developmental problems/failures–Academic –Vocational –Relationships

• Legal problems

Stress-Diathesis Model of Suicide

• Confluence of stressors and other risk factors interacting with underlying predispositions or vulnerabilities (i.e. diatheses).

General Principles of Suicide Risk Assessment

• Assessment is the beginning of treatment• Explain what you are going to do and why• Get the teen’s buy-in– ask permission!• Ask open-ended questions that cannot be

answered “yes” or “no.”• Monitor the quality of information based on

consistency with other information obtained and with non-verbal behavior

Assessment of Suicidal Behavior

• ID Risk factors• Asking about Suicidal behavior

Five Key Domains of Risk Assessment*“Risk Factors”

• Present/past suicidal ideation/behaviorPresent/past suicidal ideation/behavior• Psychiatric disordersPsychiatric disorders• Psychological traitsPsychological traits• Family and environmental stressors and Family and environmental stressors and

supportssupports• Availability of lethal agentsAvailability of lethal agents

*Brent et al. , 1997, 2001

Suicide: Distal Risk Factors

• Suicide history, personal or family• Abuse• Difficult course

• Difficult patient• Aggression• Depression• Substance Abuse

Proximal Risk Factors for Suicide

• Agitation, anxiety, akathisia• Insomnia• Despondent mood – “psychache”

• Ideation with intent• Lability – mixed state, psychosis• Lethal agents

Recognize Health Risk Behaviors Associated with Suicidal Behavior*

• Unprotected sex and STDs• Alcohol, drug, tobacco use• Weapon-carrying• Binge eating and obesity• Bullying/being bullied• Each of these can in turn increase risk of

suicidality, accident, injury, and death• LGBT

*King et al., 2001; Marshall et al., 2008

1.Characteristics of Suicidality*

• Intent/current ideation• Reasons for Living• Lethality• Precipitant• Motivation

*Hawton et al., 1982; Brent et al., 1997, 2001

Suicidal Behavior during Substance Use

• SB during intoxication• SB during recovery (detox /or

withdrawal)• SB related to SUD consequences

–Stressful life events–Psychosocial failure–Chronic neurocognitive changes

2. Psychopathology

• mood disorder, esp bipolar disorder, particularly mixed state

• Substance abuse• Conduct disorder• Eating disorders• PTSD, panic, complicated grief• Comorbidity, chronicity, severity• Developmental interactions (intent,

alcohol)

3. Psychological Characteristics

• Hopelessness (dropout, poor treatment response, attempt)

• Impulsivity and aggression (strong predictor of early-onset suicidal behavior, especially in presence of a mood disorder, familial component)

• Distress tolerance/emotion regulation• Social skills deficits (assertiveness, social problem-

solving)• Lack of Access to Positive Memories / Affect (Over-

general Autobiographic Memory)

4. Family and Social Risk Factors• Parental history of psychiatric illness suicidal behavior• Abuse and neglect, in child and in parent• Parent/child discord• Disruption of interpersonal relationships• Grief (esp. complicated grief)• Disconnection and “drifting” (Gould, 1996)• Bullying/being a bullier (girls)• Same sex attraction, transgendered (bullying, family

rejection)

Family and Social Protective Factors

• Parent-child connection• High parental expectations• Parental supervision and availability• School connection• Religious affiliation• Non-deviant peer group

5. Availability of Lethal Agents

• Guns• Medications• Drugs and Alcohol

Asking….

Hierarchical questioning• Start with hopelessness, through death wish to ideation,

intent, plan, and past attempts• History of past attempts: when, means, intent, did anyone

know– Are you disappointed that you did not succeed?

COLUMBIA-SUICIDE SEVERITY RATING SCALE (C-SSRS) Posner, Brent et al, 2009On- going Inquiry – high risk every time

Definitions of suicidality*

• Thoughts of death• Passive death wish• Thoughts of suicide, no plan or intent• Thoughts of suicide, plan and/or intent• “Aborted” suicide—person stopped self• “Interrupted” suicide– stopped by other

*Posner et al., 2007

Definitions (continued)

• Suicide attemptSuicide attempt: Intentional self-injurious behavior with at least inferred intent to die

• Suicide completionSuicide completion: Suicide attempt that results in fatality

• Don’t use the term “gesture.” (threat with a prop)

Developing a Treatment plan

• Chain analysis• Assess required level of care – based on

functioning and estimated ability to adhere to a safety plan

• Safety Plan – including securing lethal agents

• Treatment plan that decrease risk and increase protective factors

Chain Analysis

• Reconstruct events, thoughts, feelings leading up to the suicide attempt

• “Freeze frame” (Wexler, 1991)• Identifies precipitants, motivation, intent,

current reaction, reaction of environment• Identifies stressors and vulnerabilities, in

order to develop a treatment plan

From Chain Analysis to Safety Plan

• Avoid Precipitants: Don’t call girlfriend, don’t drink

• Self-coping: listening to music, exercise, meditation, avoid stressful discussion

• Reaching out: calling friend, talking with parents

• Clinical contact: therapist, on-call clinician, crisis line, ER

No-Suicide Contract

• No-suicide contracts ask youth to promise to stay alive without telling them how to stay alive

• •No-suicide contracts may provide a false sense of assurance to the clinician

• No-suicide contracts have not been shown to prevent recurrent suicidal behavior

• Instead, need a more dynamic contingency plan for coping with suicidal thoughts and anticipated stressors

What is a Safety Plan?

• Prioritized written list of coping strategies and resources for use during a suicidal crisis

• •Provides a sense of control/framework • •Brief process • •Accomplished via an easy-to-read format

using the patient’s own words • •Involves a commitment to the treatment

process (and staying alive)

Treatment Considerations

• Treat Depression, other mood and comorbid disorders– MDD, Bipolar disorder, ADHD

• Reduce Stress– Family, social (peer), school issues

• Increase ability to handle stress• Decrease “high risk” situations (including substance

use)• Safety plan and automatic responses• Decrease/stop substance use

Treatments for Adolescent with Suicidal Behavior

• Cognitive Behavior Therapy for Suicide Prevention (CBT-SP)– theoretically grounded in principles of cognitive behavior therapy,

dialectical behavioral therapy and targeted therapies for suicidal, depressed youth

– acute and continuation phases– includes a chain analysis of the suicidal event, safety plan development,

skill building, psychoeducation, family intervention, and relapse prevention.

– Drug and alcohol module to focus on role of D&A in mood and suicidal behavior

– Brent et al., 2009

Who Develops the Plan?

• Collaboratively developed by the clinician and the youth in any clinical setting

• •Youth who have -made a suicide attempt -have suicidal ideation -have psychiatric disorders that increase suicide risk -otherwise been determined to be at high risk

for suicide

When is it Appropriate?

Usually follows a suicide risk assessment • A safety plan may be done at any point during the

assessment or the treatment process • Safety plan may not be appropriate when youth are

at imminent suicide risk or have profound cognitive impairment

•The clinician should adapt the approach to the youth’s needs—such as involving family members in using the safety plan

Step 1: Recognizing Warning Signs

• Safety plan is only useful if youth can recognize the warning signs

• •The clinician should obtain an accurate account of the events that transpired before, during, and after the most recent suicidal crisis

• •Ask ―How will you know when the safety plan should be used?‖

• •Ask ―What do you experience when you start to think about suicide or feel extremely distressed?‖

• •Write down the warning signs (thoughts, images, thinking processes, mood, and/or behaviors) using the youths’ own words

Step 2: Using Internal Coping Strategies

• List activities that youth can do without contacting another person

• Activities function as a way to help youth take their minds off their problems and promote meaning in the youth’s life

• Coping strategies prevent suicidal ideation from escalating • It is useful to try to have youth cope on their own with their

suicidal feelings, even if it is just for a brief time • Ask ―What can you do, on your own, if you become suicidal

again, to help yourself not to act on your thoughts or urges?‖

Step 3: Socializing with Family Members or Others

• Coach youth to use Step 3 if Step 2 does not resolve the crisis or lower the risk

• •Family, friends, and acquaintances who may offer support and distraction from the crisis

Step 4: Contacting Family Members or Friends for Help

• Coach youth to use Step 4 if Step 3 does not resolve the crisis or lower risk

• •Ask ―How likely would you be willing to contact these individuals?‖

• •Identify potential obstacles and problem solve ways to overcome them

Step 6: Reducing the Potential for Use of Lethal Means

• Ask youth what means they would consider using during a suicidal crisis

• •Regardless, the clinician should always ask whether the patient has access to a firearm

• For methods of low lethality, clinicians may ask youth to remove or restrict their access to these methods themselves

• -For example, if youth are considering overdosing, discuss throwing out any unnecessary medication

• For methods of high lethality, collaboratively identify ways for a responsible person to secure or limit access

How to negotiate about guns

• Are there guns at home? What kind? and how are they stored?• Who owns them? • Ask these questions of the gun-owner):

– Why do you have them?– Would you be willing to consider removing

them from the home for now?– If not, would you be willing to secure them?

– Store ammunition elsewhere

Implementation: What is the Likelihood of Use?

• Ask: ―Where will you keep your safety plan?‖ • Ask: ―How likely is it that you will use the Safety Plan when

you notice the warning signs that we discussed?‖ • Ask: ―What might get in the way or serve as a barrier to your

using the safety plan?‖ • -Help the youth find ways to • overcome these barriers • -May be adapted to brief crisis cards, • cell phones or other portable • electronic devices, must be readily • accessible and easy-to-use.

Implementation: Review the Safety Plan Periodically

• Periodically review, discuss, and possibly revise the safety plan after each time it is used

-The plan is not a static document -It should be revised as youth’s

circumstances and needs change over time

Follow up

Always follow up on plan–Interim phone calls to family–Other involved professionals–Timely appointments

Document

Always Document!

What happened…What you said…Response of child/adolescent and familyPlan

Document

Always Document!If it isn’t written down, it did not happen

What happened…What you said…Response of child/adolescent and familyPlan

Discussion