Suicide and Alaskasome special topics
Richard Ries MD
[email protected]
Harborview Medical Center and the
University of Washington
Seattle, Washington
RRies Addiction and Suicide
Ries Conflict of Interest Statement
 Dr Ries is on Speaker’s bureaus for
 Janssen, and Alkermes
 Dr Ries has Grant funding from:
 NIH- NIDA
 Contingency Management Meth in Mentally Ill
 Preventing Addiction Related Suicide
 Brief Interventions of Drug Abuse in Prim Care
 CSAT
 National Co-occurring Center of Excellence
 DOD- Suicide Prevention grant
Some Facts about Suicide:
 30,000 die by suicide in USA each year
 More die by suicide than homicide (1.7 times more)
 Third leading cause of death in those 15-24 ….more than
cancer, AIDS, heart, and lung disease combined
 Males die 4x more often, but females make more attempts
 60% die by firearm
CDC web site
Facts about Suicide:
 500,000 ER visits for attempts in 1997
 Four times as many US citizens died by suicide
during the Viet Nam War period than died as
soldiers.
 Rates increase with age ( as do other causes of
death)
 Often Drug/Alcohol related
CDC web site
Risk and Lethality
 Risk of Attempt







Previous attempt
Family History of Suicide
Psychiatric disorder
Alcohol/Drug disorder
Alcohol/Drug Intoxication
Loss
Hopelessness/end of rope
 Risk of Lethality
 Male 4/1 over females
 Guns 70%
 Access




Older >70
Alone/Loss of support
Alcohol
Serious illness
 Medical
 Psychiatric
2009, United States
Suicide Injury Deaths and Rates per 100,000
All Races, Both Sexes, All Ages
ICD-10 Codes: X60-X84, Y87.0,*U03
USA Number of
Suicide Deaths
Alaska
Idaho
Washington
Oregon
Crude
Rate
Population
Age-Adjusted
Rate**
36,909
307,006,550
12.02
11.77
143
698,473
20.47
19.39
143
698,473
20.47
304
1,545,801
19.67
304
1,545,801
19.67
921
6,664,195
13.82
921
6,664,195
13.82
644
3,825,657
16.83
644
3,825,657
16.83
20.42
13.38
16.11
HOW U.S. SOLDIERS DIE
Combat
3%
Homicide
4%
Undetermined
1%
Suicide
17%
Accident
50%
Illness
25%
Suicide
accounted
for an
average of
nearly 1 in 5
deaths
among
regular and
reserve U.S.
military
personnel
between
October
1998 and
September
2003.
Source: U.S. Armed Forces
Medical Examiner, 2004
J Sch Health. 2004 May;74(5):177-82.
Attempted Suicide and associated health risk
behaviors among Native American high school
students. Shaughnessy L, Doshi SR,
The study included students in BIA-funded high schools with 10 or more
students enrolled in grades 9-12. Overall, 16% of BIA high school students
attempted suicide one or more times in the 12 months preceding the
survey.
Risk Factors:
> unintentional injury and violence behaviors,
> sexual risk behaviors,
> tobacco use, and
> alcohol and other drug use.
What about Addiction and Suicide ?
 Lifetime Suicide risk for Schizophrenic,
Affective and Addiction Disorders:
 Method: review of 83 mortality studies:
 Schizophrenia…………4%
 Affective Disorders……6%
 Addiction Disorders…...7%
Inskip HM: Br J Psych 1998
Is Suicide also Addictions Territory?
 Alcohol strongest predictor of completed suicide over 510 years after attempt, OR= 5.18…vs. demog or psych
disorders ( Beck J Stud Alc 1989)
 40-60% of completed suicides across USA/Europe are
alcohol/drug affected (Editorial: Dying for a Drink: Brit
Med J. 2001)
 Higher suicide rates (+8%) in 18 vs. 21yo legal drinking
age states for those ages (Birckmayer J: Am J Pub
Health 1999)
Modality Percents
28%
2%
9%
IP
OP
MM
Detox
39%
Lifetime Suicide Thoughts/Attempts
N=60,952
40%
30%
20%
25%
20%
20%
18%
17%
13%
13%
11%
10%
0%
IP
OP
% Thoughts
MM
Detox
% Attempted
Past 30 days Suicide
Thoughts/Attempts
N=60,952
40%
30%
20%
10%
8%
2%
5%
1%
4%
9%
2%
1%
0%
IP
OP
% Thoughts
MM
Detox
% Attempted
What do we know about Suicide Attempts in
Prospective Age-Matched Alcoholic Populations
 4.5% of alcoholics attempted suicide within 5 years of DX
 ( age 40.. n=1,237)
 0.8% in non-alcoholic matched comparison group
 ( age 42..n=2,000)…
 p< .001……….. 700 % increased risk of Suicide Attempts
Preuss/Schuckit Am J Psych 03
What Predicted Suicide Attempts in
Alcoholics (n=1,237) over 5 years?
 Rate = 4.5% attempted suicide
 Prior attempts
 Earlier onset and more severe dependence. Other
drug dependence
 Separated or divorced
 More likely to have had treatment ( more severe)
 More Panic
 More Substance Induced Psych Disorder
Preuss/Schuckit et al Am J Psych03
1: Drug Alcohol Rev. 2005 May;24(3):203-8.
Alcohol and suicide at the population level--the
Canadian experience.
Ramstedt M.
Studies suggest that the population level link between alcohol and suicide
differs across countries and between men and women. The aim of this paper
was to estimate the relationship between alcohol consumption and suicide in
Canada and to put the results in a comparative perspective.
The total suicide rate in Canada increased significantly by around
4% as alcohol consumption increased by one litre per capita,
suggesting that approximately 25 - 30% of Canadian suicides were
related to alcohol.
Suicide in Men
Suicide in Women
Standardized suicide mortality rates in men and women with mean annual
alcohol consumption in liters per capita.
Russia 1965-99.
Men
Women
Alcohol Consumption
Suicide Rates per 100,000
Alcohol consumption
Mean annual consumption with BAC-positives and BAC-negatives for
8 Russian Regions 1981-1990.
BAC Positive Suicides
BAC Negative Suicides
Alcohol Consumption
Substance Induced Depression:
Severity/Dangerousness
 Henriksson, et al (1993)- 43% of completed suicides had
alcohol dependence. 48% of these were also depressed.
42% had a personality disorder.
 Elliot, et al (1996)- patients with medically severe suicide
attempts had a statistically higher prevalence or substanceinduced mood disorder.
 Pages K et al (1997)- Higher degrees of Sub Dep related to
higher severity suicide ratings
METH ADDICTS: LIFETIME SUICIDE ATTEMPTS, BEHAVIOR PROBLEMS, AND
FELONY CHARGES, BY GENDER
ASI Item
Overall
Males Females
Test
Statistic*
Attempted Suicide (%)
27%
13%
28%
35.42**
Violent behavior problems (%)
43%
40%
46%
3.29***
Assault Charges (mean number)
0.29
0.46
0.15
4.46**
Weapons charges (mean number)
0.13
0.21
0.07
4.09**
*Mantel-Haenszel chi-square was used to test differences in proportions by gender, df=1; Student’s
two-group t-test (two-sided) was used to test differences between males and females in continuous
dependent variables reflecting the number of charges, df=1013.
Zweben, et al., 2004
**p < 0.00001 ***0.1 < p <0.05
Do Anti-depressants treat OR decrease “Suicidality”?
Am J Psychiatry. 2003 Apr;160(4):790-2.
Suicide rates in clinical trials of SSRIs, other
antidepressants, and placebo: analysis of FDA
reports.
Khan A, Khan S, Kolts R, Brown WA.
RESULTS: Of 48,277 depressed patients participating in the trials, 77
committed suicide. Based on patient exposure years, similar suicide rates
were seen among those randomly assigned to an SSRI (0.59%, 95%
confidence interval [CI]=0.31%-0.87%), a standard comparison antidepressant
(0.76%, 95% CI=0.49%-1.03%), or placebo (0.45%, 95% CI=0.01%-0.89%).
CONCLUSIONS:
These findings fail to support either an
overall difference in suicide risk between antidepressantand placebo-treated depressed subjects in controlled trials or a
difference between SSRIs and either other types of antidepressants or placebo.
Can addiction treatment affect
suicidality?
Cohort
Adults
> 25 yo (n=3524)
18-24 yo (N=651)
Adoles (n=236)
suicide attempts
Year Prior
Year After
23%...........................4%
28%...........................4%
23%...........................7%
Karageorge: National Treatment Improvement Evaluation study 2001
Alcohol Consumption, Alcoholics Anonymous
membership, and Suicide Mortality
Rates, Ontario, 1968-1991.
Mann RE, Zalcman RF, Smart RG, Rush BR, Suurvali H.
Method: We studied the impact of alcohol consumption levels, AA membership
rates, and unemployment rates on suicide mortality rates in Ontario from 1968
to
1991.
Results:
Total alcohol consumption was significantly and positively related to total
and female suicide mortality rates.
AA membership rates were negatively related to total and female suicide
rates.
(J. Stud. Alcohol 67: 445-453, 2006).
Opioid Related Death
 Opiates and Opioids have the highest death rates of
any psychoactive illicit-substances

 Accidental deaths from Prescription Opioids now
Outnumber Traffic deaths in many states
 The 2010 CDC report, Unintentional drug poisoning
in the United states, sites heroin and prescription
painkillers as the two leading causes of overdose
death in the US
Hulse, English, Mline, &
Holman, 1999; Seymour et al.
2000, CDC 2010, 2012
Overdose Planned Lethality
Fully accidental
Just blot out worries
Who cares if I wake
Lethal Plan
Opioid Deaths
 Mortality rate of opioid users 14 times that of
general population
 46% to 70% of opioid users experience one or
more non-lethal overdoses during their lifetime
 Opiate users who were recently released from
prison were at even higher risk of overdose, and
this risk may also exist post “Detox”
Suicide and Opiates
 1 in 5 (20%) of suicide victims have opiates in their
bodies at time of death, including heroin, and
prescription painkillers
 Opioid dependent adults are 14 times more likely
that their non-drug using counterparts to die by
suicide Between 33% and 50% of drug users have
a history of suicide attempts
 Suicide accounts for an estimated 3% to 35% of
deaths among heroin users
 Spectrum of Volition—
 Accidental -- Risky -- Passive SI -- Planned Suicide
Harris and Barraclough, 1997; Darke and
Ross, 2002, Ries SPOT unpub
 Risk Factors for Suicide in Opiate Abusers
Parallel Risk Factors for Accidental
Overdose(Darke and Ross, 2002)
Male gender
Accidental
Overdose
Previous
attempt
Depression
Previous
overdose
Personality
Disorder: CCD ASPD
Social isolation
Homelessness
Poly-substance abuse
Genetic predisposition
Hx. of childhood
sexual trauma
Suicide
Evidence Supported Overdose
Prevention
of Fatal
overdose
Prevention
Programs
 Methadone: opiate replacement therapies reduce opiate
overdose risk by 75%
 Naloxone: ER administered Naloxone, peer administered
Naloxone (I.M., I.V., S.Q., intranasil).
 Medically supervised injection facilities: report 0 fatal
overdose deaths.
 Educational programs: presented at needle exchange
programs
 Protocols: limiting police intervention in during overdose
emergencies
Gunne and Gronbladhm, 1981; Bammer, 2000;
McGregor, Ali Christie, Darke, 2001
Preventing Addiction Related Suicie (PARS)
NIDA R21
Ries, Voss, Comtois,
Addictions staff and directors
 Designed to be a single 3 hour IOP session integrated into typical outpt
Addictions Treatment programs—for all patients in treatment

 To enhance positive changes in Attitudes, Knowledge, and Adaptive
Skills for suicidal issues in both patients and those around them,
workbook based,
 Needing only a single 3 hour staff training session—using same guide
they then use to perform and guide group.
 Designed iterively with REAL WORLD addictions staff, administrators,
and patients for feasabiity
 RETRAINS STAFF EACH TIME USED IN IOP, OR OTHER FORMAT
Pilot Data PARS
In the past 30 days, have you
asked for help because you
were having suicidal
thoughts/feelings.
Pre-test
No
97%
(n=60)
YES
3%
(n=2)
1 month
follow-up
90%
(n=56)
10% (n=6)
P=.000
In the past 30 days, have you
asked a friend to get help
because you were worried
that he or she was having
suicidal thoughts/feelings.
Pre-test
NO
YES
1-month
follow-up
94%
(n=59)
78%
(n=49)
6%
(n=4)
22%
(n=14)
P=.009
Suicide Resources:
 American Association of Suicidology: www.suicidology.org
 American Foundation for Suicide Prevention:
www.afsp.org
 National Strategy for Suicide Prevention:
www.mentalhealth.org/suicideprevention/
 National Suicide Prevention Strategy
www.sg.gov/library/calltoaction/
 CDC
Suicide Resources:
 Suicide Prevention Advocacy Network (SPAN)
www.spanusa.org
 QPR institute: www.qprinstitute.com
 Substance Abuse and Mental Health Services
Administration: www.samhsa.gov
 Tip 50- Addiction and Suicide www.CSAT.gov
Now lets talk about some
of YOUR issues
 Suicide Assessment
 Suicide prevention
 Suicide Treatment
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PARS - Washington Association of Alcoholism and Addiction