<p> Title: Acute Alcohol Use and Suicide Attempts</p><p>Courtney L. Bagge, Ph.D.</p><p>Department of Psychiatry and Human Behavior</p><p>University of Mississippi Medical Center</p><p>Alcohol Medical Scholars Program (Slide 1)</p><p>I. Introduction </p><p>A. Suicidal behavior is common in US (Slide 2)</p><p>1. > 36,000 die by suicide </p><p>2. 10th cause of death in US1 </p><p>3. ~5 nonfatal attempts per 1 completion2 </p><p>B. Alcohol use & misuse also common in US (Slide 3) 1. ~ 90% use alc lifetime</p><p>2. 53% use alc past yr3</p><p>3. 15% lifetime abuse4 (I define later)</p><p>4. 10% lifetime dependence4</p><p>C. There is overlap: use, misuse, attempt (Slide 4)</p><p>1. Attempters who acutely use prior to act: ~30% have AUD9</p><p>2. Attempters w/ AUD: ~70% acutely use prior to act6</p><p>D. Clinical Case Eg: Is person at risk for alcohol-related suicide? (Slide 5)</p><p>1. Visits primary care physician for check-up </p><p>2. 30 yr. old female</p><p>3. Drinking: 1 X every 2 mo. (1-2 drinks)</p><p>4. No suicidal thoughts </p><p>1 5. No history of depression (known risk factor for suicide)</p><p>6. Mentions relationship difficulties</p><p>E. This lecture will cover: (Slide 6)</p><p>1. Definitions of suicidality and chronic/acute alcohol use</p><p>2. How acute alcohol use and suicide attempts relate</p><p>3. Possible reasons for drinking at attempt </p><p>4. Prevention and treatment implications </p><p>II. Definitions </p><p>A. Suicidality (Slide 7)</p><p>1. Suicidal thoughts (or ideation):Thoughts of killing oneself</p><p>2. Suicidal behavior: Self-inflicted behavior w/intent to die</p><p> a. Suicide: Fatal outcome</p><p> b. Attempt: Non-fatal outcome</p><p>B. Alcohol</p><p>1. Drink (10-12g ethanol) (Slide 8)</p><p> a. Beer: 12 oz/355 ml</p><p> b. Wine: 4 oz/120 ml</p><p> c. Spirits (gin): 1.5 oz/44 ml</p><p>2. Drinking patterns (Slide 9)</p><p> a. Quantity frequency </p><p> b. Heavy episodic7 </p><p>1’ 5+ drinks/session ♂ </p><p>2 2’ 4+ drinks/session ♀</p><p>3. Binge15: </p><p> a. Prolonged exposure: Intoxicated > 2 days </p><p> b. Give up usual activities for intoxication </p><p>4. Alcohol Use Disorders (AUD)16 (Slide 10)</p><p> a. Alcohol abuse: Repeated alc problems in same 12 mo. with ≥ 1 of:</p><p>1’ Inability to fulfill role obligation</p><p>2’ Use in physically hazardous situations (eg, driving)</p><p>3’ Legal problems</p><p>4’ Social or interpersonal problems</p><p>5’ Not dependence</p><p> b. Alcohol dependence: Repeated alc problems over 12 mo. w/ ≥ 3 of:</p><p>1’ Tolerance: ↑ use for same effect; ↓ effect w/same amount</p><p>2’ Withdrawal: Symptoms opposite of intake </p><p>3’ Use heavier or longer than intended</p><p>4’ Desire and inability to cut down</p><p>5’ ↓ activities in order to drink</p><p>6’ Much time spent in alcohol-related activities</p><p>7’ Ongoing use despite consequences</p><p>5. Acute alcohol use (Slide 11)</p><p> a. For alcohol: Any 1 instance of drinking</p><p> b. For suicide: 1 specific instance of drinking (prior to attempt)</p><p>3 1’ Drinking any alcohol </p><p>2’ Drinking to intoxication </p><p>3’ Usually within 3-6 hours of attempt </p><p>III. How acute alcohol use and suicide attempts relate (Slide 12)</p><p>A. Descriptive statistics use on day of attempt (Slide 13)</p><p>1. ~ 40%5 attempters used alcohol on attempt day </p><p>2. Subgroups differ re use on that day17,18</p><p> a. Men (53%) > women (40%) </p><p> b. < age 51 greater than older ages </p><p> c. ↑ AUD </p><p>3. Limitations</p><p> d. Rates only descriptive (No control group)</p><p> e. Not evidence of association </p><p>B. Case-control research: Who is likely to attempt? (Slide 14)</p><p>1. Design19</p><p> a. Compare 2 groups on recent alcohol exposure </p><p> b. E.g., ER patients: after attempt vs. non-suicidal injury </p><p>2. Key findings (Slide 15)</p><p> a. Risk ↑ with higher dose10</p><p> b. Acute use of > 100 grams → ~60X ↑ risk 10 </p><p> c. Chronic use of > 100 grams/day → 3X ↑ risk 10</p><p> d. Modeled together: Acute use ↑ risk ≥than chronic use </p><p>4 1’ Acute use: > effect (OR = ~6, p < .05)11</p><p>2’ Chronic use no longer ↑ risk</p><p>3. Design Limitations</p><p> a. No consensus who best control group</p><p> b. Can’t control for all case-control differences (e.g., race, age, SES, etc.)</p><p>C. Case-crossover studies: When is someone likely to attempt? (Slide 16)</p><p>1. Design15</p><p> a. Compare 1 person on 2 occasions/periods</p><p> b. E.g., 6 hrs. prior to attempt vs. matched 6 hrs. prior period</p><p> c. Best control group patient himself</p><p>2. Key findings: (Slide 17)</p><p> a. ↑ attempt risk while drinking (large effect; RR=~10x) 21</p><p> b. Occurs regardless of sex, age, marital status21</p><p> c. So, acute drink ↑ risk 4 all but…</p><p> d. Acute drinking ↑ risk infrequent drinkers (< 1/ mo.) than others21</p><p> e. Highlights clinical importance esp. for infrequent drinkers</p><p> f. A group rarely targeted for prevention</p><p>D. Acknowledge 3rd variables could explain results </p><p>1. Alc may not→ attempt, but relate to other item</p><p> a. Time of day of attempt</p><p> b. Place event occurs</p><p> c. Situation surrounding event</p><p>5 2. Situational events may → both acute drinking and attempt e.g., 22</p><p> a. Relationship break up</p><p> b. Assault</p><p> c. Bereavement </p><p>IV. Possible reasons for drinking on day of attempt (Slide 18)</p><p>A. Non-suicide related reasons (Slide 19)</p><p>1. Context for drinking23</p><p> a. Social: To be sociable</p><p> b. Enhancement: To get high</p><p> c. Coping: To forget worries</p><p>2. Prevalence: </p><p> a. If drink on day attempt majority drink for non-suicide reasons (67%)24 </p><p> b. Out of those who drank for non-suicide related reasons:</p><p>1’ ~60% believed alcohol not → attempt24</p><p>2’ ~40%: believed alcohol → poor judgment 24</p><p>3. Potential reasons drinking for non-suicidal reasons ↑risk22, 25: </p><p> a. ↑ psychological distress </p><p> b. ↑ depressed mood and anxiety</p><p> c. ↑ aggressiveness and impulsivity</p><p> d. All or nothing thinking: must solve problem or kill self </p><p> e. Alcohol myopia: Attentional short-sightedness26</p><p>1’ Focus on present environment such as</p><p>6 a’ Why life is bad</p><p> b’ Current pain</p><p>2’ Can’t think of reasons for living such as</p><p> a’ Family devastated</p><p> b’ Emotional pain can’t last </p><p>B. Suicide-related reasons (Slide 20)</p><p>1. Context22, 25</p><p> a. Drink to facilitate suicide attempt</p><p> b. Drink as suicide method </p><p>2. Prevalence</p><p> a. Up to 33% alcohol facilitate attempt 24, 27 </p><p> b. Up to 26% used as method 28,29 </p><p>3. Mechanisms22, 25</p><p> a. To enable suicide by other means</p><p>1’ ↑courage</p><p>2’ Anesthetizing pain of dying </p><p> b. As (or part of) method 22, 25</p><p>1’ Alcohol poisoning </p><p>2’ Interaction alcohol w/ medications /drugs</p><p>V. Prevention and treatment implications (Slide 21)</p><p>A. Why docs should know about important risk factors for suicide? (Slide 22)</p><p>1. Provider likely contacted in month prior to suicide </p><p>7 a. ~45% met w/ primary care physician12</p><p> b. ~20% met with mental health provider12</p><p>2. Thus, many seek help from primary care13 </p><p>B. Alcohol use and suicide attempts co-occur </p><p>C. Doctor’s visits unique opportunity for prevention/ intervention </p><p>D. Docs: If patient has alcohol OR suicidal thoughts - evaluate both (Slide 23)</p><p>1. Screening: Other there?</p><p>2. Monitoring: How both change over time?</p><p>3. Prevention: If other is not there, how prevent? </p><p>4. Treatment: How improve/change both? </p><p>E. Doc ask about suicidal thoughts/attempts among drinkers</p><p>1. Don’t be afraid to ask </p><p> a. Does not ↑ or cause suicide 30, 31 </p><p> b. For high-risk patients: asking can ↓ suicidal thoughts & distress30</p><p>2. Suicide queries: evidence-based tools32 (Slide 24)</p><p> a. Use a stepwise progression: </p><p>1’ Ever thought about death/dying?</p><p>2’ Ever thought life not worth living?</p><p>3’ Ever thought about ending life?</p><p>4’ Ever attempted suicide?</p><p>5’ Currently thinking about ending life?</p><p>6’ Reasons for die and live?</p><p>8 b. Avoid “faking good” </p><p>1’ Ask all questions</p><p>2’ Patient may say:</p><p> a’ “No” to first query</p><p> b’ “Yes” to later </p><p> c. If suicidal ideation is +, ask : </p><p>1’ Frequency, intensity, duration of thoughts</p><p>2’ Existence of plan/preparatory steps</p><p>3’ Intent </p><p> a’ How much want to die</p><p> b’ How likely carry out thoughts/plans</p><p>F. Docs ask ALL patients: Alc use/patterns & motives (Slide 25)</p><p>1. Alc use/patterns: evidence-based tools</p><p> a. Patterns: Alcohol Use Disorders Identification Test-C (AUDIT-C)33</p><p> b. 3 Questions</p><p>1’ Frequency of use: When? (E.g. monthly, weekly, ~daily?)</p><p> a’ Never 0 </p><p> b’ Monthly or less 1 </p><p> c’ Two to four times a month 2 </p><p> d’ Two to three times a week 3 </p><p> e’ Four or more times a week 4 </p><p>2’ # drinks consumed/typical drinking day</p><p>9 a’ None, I do not drink 0 </p><p> b’ 1 or 2: 0 </p><p> c’ 3 or 4: 1 </p><p> d’ 5 or 6: 2 </p><p> e’ 7 to 9: 3 </p><p> f’ 10 or more: 4</p><p>3’ Frequency of heavy episodic use (≥ 5 drinks/d [men]; ≥ 4 [female])</p><p> a’ Never 0 </p><p> b’ Less than monthly 1 </p><p> c’ Monthly 2 </p><p> d’ Weekly 3 </p><p> e’ Daily or almost daily 4</p><p> c. Scoring: scale of 0-12</p><p>1’ Screening ≠ diagnosis → + screen requires full evaluation</p><p>2’ AUD → Men > 4; Women > 3 </p><p>3’ Sensitivity → 80-90%; specificity → 60-70%</p><p>2. Drinking reasons: evidence-based tools (Slide 26)</p><p> a. Ask why patient drinks</p><p> b. If drinking to cope: </p><p>1’↑ risk for suicidal thoughts 34 </p><p>2’ Examples include23</p><p> a’ To cheer up </p><p>10 b’ Helps when get depressed</p><p> c’ To forget worries</p><p>3’ Help patient find other coping strategies </p><p> a’ How coped in past w/out alcohol?</p><p> b’ Other things worked before to cheer up like: </p><p>(1) Call friend</p><p>(2) Walk in park</p><p>(3) Watch comedy</p><p>3. Docs remember: Don’t ignore infrequent drink or non AUD </p><p> a. Prelim. Evid.: Infrequent drinkers ↑ suicide risk while drinking21</p><p> b. Acute alcohol may trigger suicide attempt21</p><p>G. Using clinical case to demonstrate some of steps presented above (Slide 27)</p><p>1. Initial primary care physician evaluation-recap</p><p> a. Using evidenced based tools above</p><p>1’ No suicide thoughts or past attempts</p><p>2’ She drank < 1 mo; 1-2 drinks per occasion</p><p>3’ No evidence of AUD </p><p> b. Mentions relationship problems</p><p> c. View at alcohol-related risk for suicide?</p><p> d. What is missing, such as</p><p>1’ How cope?</p><p>2’ Reasons use alcohol?</p><p>11 2. What happened to patient? (Slide 28)</p><p> a. Boyfriend broke up with her</p><p> b. She attempted suicide</p><p> c. Brought to the ER by family and reported </p><p>1’ Used alcohol for coping</p><p>2’ Thought about suicide shortly before attempt</p><p>3. Was drinking connected to attempt?</p><p> a. Not enough information yet</p><p> b. Could have drank early in the morning & attempt at night</p><p> c. Don’t know whether they are connected</p><p>H. Doc explore alcohol and suicide connection [case info incorporated in brackets] (Slide 29)</p><p>1. Goal: help prevent future alc/suicide acts</p><p>2. Consider behavior chain analysis32</p><p> a. Discuss most recent alc/suicide episode</p><p> b. Identify when problem started [break-up]</p><p> c. Discuss how vulnerable to problem</p><p>1’ Physical illness [none]</p><p>2’ Not taking medications [no]</p><p>3’ Eat too little/much [skip lunch]</p><p>4’ Sleep too little/much [stayed up late]</p><p>5’ Drug use [none]</p><p>5’ Alcohol use [none prior to when problem started]</p><p>12 d. Discuss prompts to alc &/or suicide at that time (Slide 30)</p><p>1’ What thinking? [“I’ll never find anyone else”] </p><p>2’ Neg. Mood on 1 (none) -10 (worst) scale [9]</p><p>3’ Anger on 1 to 10 scale [7]</p><p>4’ What did you do? [drive to a bar]</p><p> e. Identify next event/link [order 1st beer at bar] </p><p>1’ What thinking? [“I’m going to forget about him”] </p><p>2’ Mood on 1 (none) -10 (worst) scale [7]</p><p>3’ Anger on 1 to 10 scale [7]</p><p>4’ What did you do? [drink]</p><p> f. Identify next event/link [order 2nd beer at bar] </p><p>1’ What thinking? [“I feel better. I don’t need him”] </p><p>2’ Mood on 1 (none) -10 (worst) scale [5]</p><p>3’ Anger on 1 to 10 scale [5]</p><p>4’ What did you do? [order another beer]</p><p> g. Identify next event/link [order 4th beer at bar] </p><p>1’ What thinking? [“I can’t live without him”] </p><p>2’ Mood on 1 (none) -10 (worst) scale [9]</p><p>3’ Anger on 1 to 10 scale [7]</p><p>4’ What did you do? [bathroom; take 100 tylenol]</p><p> h. Discuss how felt after alc related suicide attempt</p><p>1’ How feel right afterwards? [scared]</p><p>13 2’ How others react? [boyfriend didn’t want to date]</p><p> i. Identify “links in chain” for solutions </p><p>1’ How prevent initial event (change how was vulnerable)</p><p> a’ Now eat regularly-even if don’t feel like it</p><p> b’ Now regular sleep-wake up same time</p><p>2’ Where could have done something different </p><p> a’ Instead of X [bar], what could have done [walk w/friend]? </p><p> b’ Instead of y [drink], what worked in past [relax exercise]?</p><p>3. Process useful for:</p><p> a. Generating specific solutions </p><p> b. Prevent future problems</p><p>I. Consider Dialectical Behavior Therapy32: (Slide 31)</p><p>1. Teaches skills to ↓ both behaviors</p><p>2. 4 types of skills: ↑ ability to </p><p> a. Focus on here-and-now</p><p> b. Have positive interpersonal relations</p><p> c. Regulate emotions</p><p> d. Tolerate bad situations and negative emotions</p><p>II. Summary (Slide 32 and 33)</p><p>A. Relations</p><p>1. 40% drink on day of attempt 14 2. 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