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Suicidal Behavior, Alcohol, and Alcohol

Use Disorders

Timothy W. Lineberry, M.D.

Assistant Professor, Psychiatry

Mayo Clinic

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US Prevalence Suicidal Behavior

%/yr #/yr

Thoughts 3.3 9,900,000

Attempts0.6

(4.6 Lifetime)

1,800,000

(13,800,000)

Suicide ~ 0.01 >32,000

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%/yr

(Lifetime)

#/yr

(Lifetime)

Hazardous 25 75,000,000

Abuse5

(18)

15,000,000

(54,000,000)

Dependence4

(13)

12,000,000

(39,000,000)

US Prevalence Alcohol Use Disorders

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This Lecture will Cover

• Definitions

• Relationship

• Screening & identification

• Assessment & management

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Hazardous Drinking

• Men 5 drinks/day or 15 drinks/week

• Women 4 drinks/day or 8 drinks/week

• “At risk” for alcohol-related problems

• NOT alcohol abuse or dependence

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Alcohol Abuse

– 12-month pattern of problems in 1 of:

• Inability to meet obligations

• Physically hazardous situations

• Legal problems

• Social or interpersonal problems

– Not alcohol dependence

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Alcohol Dependence

• 12-month pattern of problems in 3 of:

– Tolerance: use = same effect– Withdrawal: Use to relieve/avoid withdrawal– Use larger amounts/longer than intended– Desire to or unsuccessful efforts to cut down time spent in alcohol-related activities– Give up important social activities– Continued use despite persistent problems

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Major Depressive Disorder (MDD)

• MDD lifetime prevalence: ♀ 15%: ♂ 8%

• Must represent change in function

• Subjective report or observation of others

• > 5 symptoms nearly daily for 2-weeks

• Must have at ≥ 1 of following 2

1. Depressed mood most of the day

2. ↓ interest/pleasure in most activities

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Additional MDD Criteria

• Weight ↓ or ↑ or appetite ↓ or ↑

• Sleep ↓ or ↑

• Psychomotor agitation or retardation

• Fatigue or ↓ energy

• Feelings of worthlessness or inappropriate guilt

• ↓ Ability to think/concentrate or indecisiveness

• Recurrent SI or thoughts of death

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Suicide-related Behavior

• Ideation = thoughts of

• Attempt = deliberate self-harm

• Completion = death from attempt

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This Lecture will Cover

• Definitions

• Relationship

• Screening & identification

• Assessment & management

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Alcohol Use Disorders and Suicide

Alcohol use disorders

Suicide

~25%

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Alcohol Dependence and Suicide

• Suicidal ideation ↑ 3-5X

• Suicide attempts ↑ 4-6X

• Lifetime suicide rate 7-10%

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Major Depression

• ~40% of suicides have MDD• 20% with MDD attempt in lifetime • Lifetime suicide rate varies with

severity of depressive illness–Psych. hospitalized + SI: 9%–Hospitalized without SI: 4%–Outpt. depression: 2%

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Depression and suicideDepression

Suicide

~40%

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Which came First?

• 80% of patients with alcohol dependence report lifetime depressive symptoms

• Sustained heavy alcohol use induces depressive symptoms

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“Independent” MDD

• Predates alcohol dependence diagnosis or occurs in times of sustained abstinence

• More likely to have family history of MDD

• 15% of alc dependence patients

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Alcohol Induced MDD

• Temporary sxs associated with use

–Typically resolve in ~ 4 weeks

• Resolve with sustained abstinence

• Family history of MDD less likely

• 26% of alc dependence patients

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Alcohol Dependence and MDD

MDDAlcohol Dependence

Alcohol Induced 26%

Independent 15%

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Depression + Alcohol Dependence

Suicide rate

• Independent depression ↑ suicide attempt rate vs. alcohol induced

• Increasing age risk for both

• Depression and alcohol use disorder make up ~65% of all suicides

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Major Depression

Suicide-related behaviorsAlcohol use disorders

Alcohol Use Disorders are Related to Suicide

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This Lecture will Cover

• Definitions

• Relationship

• Screening & identification

• Assessment & management

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Ask Everyone!

• <25% patients routinely screened for alcohol use

• ~ 40% with MDD missed by primary MD

• 35% with known MDD asked about suicide

• MDs report discomfort with asking

• MDs miss obvious clinical patterns

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Patients Expect

• To be asked about alcohol use

• To be asked about emotional problems

• Guidance about use and risky behaviors

• Judge MD skill based on their attention to

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Evidence Based Screening

• Screening ≠ diagnosis• Screening tools include

– History– Survey– Physical exam– State markers (laboratory)

• + Screen requires full evaluation

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CAGE

• Cut down, Annoyed, Guilt, Eye-opener

• Positive test > 2 yes answers • Sensitivity → 50-80%• Specificity → ~ 80%• Doesn’t screen for hazardous

drinking

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AUDIT

• 10-item survey

• Developed by W.H.O.

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

• Sensitivity → ~70%

• Specificity → 80%

• 3-item survey

• Sensitivity/specificity

= to 10-item AUDIT

• Positive score

– Men > 4

– Women ≥ 3

AUDIT-C

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Physical Examination

3 drinks/day risk of hypertension

Hepatosplenomegaly (liver/spleen size

)Peripheral neuropathy: 15% w/alc

dep

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State Markers

• Blood tests

• Change with heavy sustained alcohol use

– Gamma-glutamyl transferase (GGT)

– Carbohydrate Deficient Transferrin (CDT)

– CBC w/Mean Corpuscular Volume (MCV)

– Aspartate transaminase (AST)

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2 Question Depression Screening

• In the past month… 1. Have you been bothered by feeling

down, depressed, or hopeless? 2. Have you been bothered by little

interest/pleasure in doing things?• ≥ 1 yes = positive test• Sensitivity: 96%; specificity: 57%• Remember! screening ≠ diagnosis

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This Lecture will Cover

• Definitions

• Relationship

• Screening & identification

• Assessment & management

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Manage At Risk Patients

Positive screenHistory, survey, physical exam, state markers

Full evaluation

Use diagnostic criteria

Evidence-based treatments

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Define MDD in Alcohol Use

Timeline interview

Carefully assess lifetime MDD sxs

Sxs present w/sustained abstinence?

Family history of depression?

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Evidence Based Treatments

• Motivational Interviewing

• Cognitive Behavioral Therapy

• Disulfiram

• Naltrexone

• Acamprosate

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SAFE-T Suicide Risk Assessment

Risk factors

Protective factors

Suicide inquiry

Assess risk & level of care

Document

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Intent

Plan

Suicidal ideation

Thoughts of death

Hopelessness

Stepwise assessment

©AMSP 200841

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Assess Risk and Level of Care

• Clinical judgment

• Low risk → outpt follow-up

• Moderate → psychiatry/ER

• High → hospitalization

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Summary

• Definitions

• Relationship

• Screening & identification

• Assessment & management