Suicidality &
Substance Abuse
Bruce Michael Cappo, Ph.D.
Clinical Associates, P.A.
Quo Vadis
Intro
Statistics
Causality
Substance factors
Risk Factors
What we know
What to do
2
The Three Hs:
Hopelessness
Helplessness
Haplessness
3
Hopelessness
Strongest predictor of suicide
Stronger even than depression
Only people who have lost all hope kill
themselves. Do whatever you can to build
hope - however small it may be. They
want to have hope in the future.
4
Helplessness
The person views him or herself as being
absolutely unable to make any changes to
the situation or to his/her life
This characteristic should signal a high
risk situation for you.
5
Haplessness
These people often have very sad lives
25% have a family history of successful suicidal
behavior in a relative
Higher percentage who have histories of mental
illness, depression, abuse, divorces, frequent
moves and periods of unemployment in their
family
Often there are multiple problems at the same
time which just become too overwhelming.
6
Suicide is a tragic and potentially
preventable public health problem
8th leading cause of death in the U.S.
10.6 out of every 100,000 persons died by
suicide
7
The total number of suicides was
approximately 31,000, or 1.3 percent of all
deaths.
Approximately 500,000 people receive
emergency room treatment as a result of
attempted suicide each year
8
Substance Use and the Risk
of Suicide Among Youths
Approximately 3 million
youths were at risk for suicide
during the past year
9
Substance Use and the Risk
of Suicide Among Youths
Youths who reported past
year alcohol or illicit drug use
were more likely than youths
who did not use these
substances to be at risk for
suicide
10
Substance Use and the Risk
of Suicide Among Youths
Only 36 percent of youths at
risk for suicide during the past
year received mental health
treatment or counseling
11
12
Underestmated Numbers?
Authorities agree that many
suicides are not reported, but the
National Center for Health
Statistics records between 25,000
and 30,000 self-inflicted deaths in
the U.S. annually.
15
Attempts vs Completions
For every death from suicide, experts
estimate that eight other suicide attempts
are made. Suicide is now the second
leading cause of death among persons 15
to 24 years of age. It is increasingly a
problem among adolescents and elderly
people.
16
Statistical Indicators of Risk
Previous suicide attempts
The verbalizing of suicide threats
The giving away of prized personal
possessions
The collection and discussion of
information on suicide methods
17
Statistical Indicators of Risk
The expression of hopelessness,
helplessness, and anger at oneself or the
world
Themes of death or depression evident in
conversation, written expressions, reading
selections, or artwork
18
Statistical Indicators of Risk
Statements or suggestions that the
speaker would not be missed if he or she
were gone
Physical symptoms such as eating
disturbances, sleeplessness or excessive
sleeping, chronic headaches or
stomachaches, menstrual irregularities,
apathetic appearance
19
Statistical Indicators of Risk
Use or increased use of substances
Look for sudden changes in behavior that
are significant, last for a long time, and are
apparent in all or most areas of his or her
life (pervasive).
20
Often occur prior to acts of self-harm
The scratching or marking of the body, or
other self-destructive acts
Recent loss of a friend or a family member
(or even a pet) through death or suicide;
other losses (for example, loss of a parent
resulting from divorce)
21
Often occur prior to acts of self-harm
Acute personality changes, unusual
withdrawal, aggressiveness, moodiness,
or new involvement in high-risk activities.
Sudden dramatic decline or improvement
in academic performance, chronic truancy,
tardiness, or running away
22
Who is at highest risk for suicide
in the U.S.?
Common misperception that suicide rates
are highest among the young
Elderly, particularly older white males
have the highest rates
Among white males 65 and older, risk
goes up with age
23
Who is at highest risk for suicide
in the U.S.?
White men 85 and older have a suicide rate that
is six times the national rate
 White males are more deliberate in their suicide
intentions
They use more lethal methods (firearms) & don’t
tell of their plans
Older persons are less likely to survive attempts
because they are less likely to recuperate
24
"They [researchers] cite a wide range of
potential suicide triggers, from loss of
employment or loved ones, to aging and
physical impairment. But, in almost all
cases, they agree there is an underlying
psychiatric illness-primarily depression,
followed by alcoholism and substance
abuse."
"The Mystery of Suicide," Newsweek,
April 18, 1994
Causality
No cause-and-effect relationship
between use of alcohol and/or other
drugs and suicide has been
established
Substances often identified as a
contributing factor
26
Possible Explanations
Drinking, use of other drugs, or both may
reduce inhibitions and impair the judgment
of someone contemplating suicide,
making the act more likely
Use may also may aggravate other risk
factors for suicide such as depression or
other mental illness.
27
Alcohol/other drug problem
prevention in reducing suicides:
High rates of alcohol involvement have
been found among suicide victims who
use firearms.
Recent studies suggest that alcohol tends
to be associated with impulsive rather
than premeditated suicides
28
Alcohol/other drug problem
prevention in reducing suicides:
Between 20 and 35 percent of suicide
victims had a history of alcohol abuse or
were drinking shortly before their suicides
29
Alcohol/other drug problem
prevention in reducing suicides:
Nearly 24 percent of suicide victims had
blood alcohol concentrations (BACs) of
.10 or greater
Similarly, an analysis of 100,000 deaths in
1989 found positive BACs in 35 percent of
suicide fatalities
30
Alcohol/other drug problem
prevention in reducing suicides:
In one study of youthful suicide, drug and
alcohol abuse was the most common
characteristic of those who attempted
suicide
Fully 70 percent of these young people
frequently used alcohol and/or other drugs
31
Alcohol/other drug problem
prevention in reducing suicides:
In 1989, the cost of providing health care
for people who had attempted suicide was
estimated at $116.4 million annually
32
Alcohol/other drug problem
prevention in reducing suicides:
Prevention works, and preventing alcohol,
tobacco, and other drug problems also
can help prevent suicide.
33
Does alcohol and other drug abuse
increase the risk for suicide?
A number of recent national surveys have
helped shed light on the relationship
between alcohol and other drug use and
suicidal behavior. A review of minimumage drinking laws and suicides among
youths age 18 to 20 found that lower
minimum-age drinking laws was
associated with higher youth suicide rates
34
Does alcohol and other drug abuse
increase the risk for suicide?
 In a study of all non-traffic injury deaths
associated with alcohol intoxication, over
20 percent were suicides.
35
Does alcohol and other drug abuse
increase the risk for suicide?
Lower minimum-age drinking laws are
associated with higher youth suicide rates
For particular groups at risk, such as
American Indians and Alaskan Natives,
depression and alcohol use and abuse are
the most common risk factors for
completed suicide
36
Does alcohol and other drug abuse
increase the risk for suicide?
In a large study of adults who drink
alcohol, suicidal ideation was more likely
reported among persons with depression
Persons who had made a suicide attempt
were more likely to have had a depressive
disorder and many also had an alcohol
and/or substance abuse disorder
37
Other Risk Factors
Aggressive behavior doubled suicide risk
among boys
Panic attacks nearly tripled suicide risk for
girls
Being a teenage runaway nearly tripled
suicide risk
Perfectionism has also been linked to
suicide in some studies
38
Substance Abuse May Escalate Suicidal Ideas
to Attempts in Teens
A study in the September issue of the
Journal of the American Academy of Child
and Adolescent Psychiatry provides
important insights into the relationships
between psychiatric disorders and
adolescent suicide, suggesting that teens
who abuse drugs or alcohol are more
likely to progress from suicidal thoughts to
39
suicide attempts
Substance Abuse May Escalate Suicidal Ideas
to Attempts in Teens
The research assessed the links among
suicidal ideas, suicide attempts, and
adolescent psychiatric disorders in a
random sample of nearly 1,300 children
aged 9 to 17 years. Of these,
67 had had suicidal thoughts
42 had made suicide attempts.
Adjusted for age and gender
40
Substance Abuse May Escalate Suicidal Ideas
to Attempts in Teens
suicide attempts were significantly more
likely for youngsters with mood disorders
(depression and bipolar disorder), anxiety
disorders, and substance abuse or
dependence issues.
41
In order to find it you must look
Recognition and appropriate treatment of
mental and substance abuse disorders
also hold great suicide prevention value
Most elderly suicide victims --70 percent -have visited their primary care physician in
the month prior to their suicides
Recognition and treatment of substance
abuse and depression in medical settings
can help prevent suicide in older adults 42
Risk factors among people who
have completed suicide
For particular groups at risk, such as
American Indians and Alaskan Natives,
depression and alcohol use and abuse are
the most common risk factors for
completed suicide.
Substance use & abuse occurs more
frequently among youth and adults,
compared to older persons.
43
Alcohol and substance abuse problems
contribute to suicidal behavior
 Persons who are dependent on
substances often have a number of other
risk factors for suicide.
In addition to being depressed, they are
also more likely to have social and
financial problems.
44
Alcohol and substance abuse problems
contribute to suicidal behavior
Substance use and abuse can be
common among persons prone to be
impulsive, and among persons who
engage in many types of high risk
behaviors that result in self-harm
45
What are the most common
methods of suicide?
Firearms
For men and women
60 percent of all suicides
Nearly 80 percent of all firearm suicides
are committed by white males
46
Common Methods
The second most common method for
men is hanging
The second most common method for
women is self-poisoning including drug
overdose
47
Common Methods
The presence of a firearm in the home
has been found to be an independent,
additional risk factor for suicide. Thus,
when a family member or health care
provider is faced with an individual at risk
for suicide, they should make sure that
firearms are removed from the home.
48
Male - Female Differences
More than four times as many men as
women die by suicide
Women attempt suicide more often during
their lives than do men
Women report higher rates of depression.
49
Why the Gender Differences?
Completed suicide is associated with
aggressive behavior that is more common
in men
Men and women use different suicide
methods
50
Why the Gender Differences?
Women in all countries are more likely to
ingest poisons than men
In countries where the poisons are highly
lethal and/or where treatment resources
scarce, rescue is rare and hence female
suicides outnumber males
51
If someone tells you they are
thinking about suicide
Take their distress seriously
Listen non-judgmentally
Evaluate & get them to appropriate
treatment
People consider suicide when they are
hopeless and unable to see alternative
solutions to problems
52
If someone tells you they are
thinking about suicide
Suicidal behavior is also more likely to
occur when people experience stressful
events (major losses, incarceration)
If someone is in imminent danger of
harming himself or herself, do not leave
the person alone.
Limit access to firearms or other lethal
means of committing suicide.
53
Are African American youth at
great risk for suicide?
Historically, African Americans have had much
lower rates of suicides
Rising at a faster rate for African American male
youth
Trend is for a decrease in suicide across all
gender and racial groups
Increase in suicide by firearms for all young
males
‘Victim precipitated homicide’ in Black Males?
54
Is suicide related to impulsiveness?
The mental disorders with impulsiveness
most linked to suicide include borderline
personality disorder among young
females, conduct disorder among young
males and antisocial behavior in adult
males, and alcohol and substance abuse
among young and middle-aged males
55
Is suicide related to impulsiveness?
Impulsiveness appears to have a lesser
role in older adult suicides
ADHD is not a strong risk factor for
suicide
Impulsiveness has been linked with
aggressive and violent behaviors
Impulsiveness without aggression or
violence present has also been found to
contribute to risk for suicide.
56
What biological factors increase
risk for suicide?
Depression and suicidal behavior can be
linked to decreased serotonin
Low levels of a serotonin metabolite, 5HIAA, have been detected in CSF in
persons who have attempted suicide, as
well as by postmortem studies of suicide
victims
57
Can the risk for suicide be inherited?
Growing evidence that familial and genetic
factors contribute to the risk for suicidal
behavior
Major psychiatric illnesses, including
bipolar disorder, major depression,
schizophrenia, alcoholism and substance
abuse, and certain personality disorders,
which run in families, increase the risk for
suicidal behavior
58
Can the risk for suicide be inherited?
This does not mean that suicidal behavior
is inevitable for individuals with this family
history
Such persons may be more vulnerable
and should take steps to reduce their risk,
such as getting evaluation and treatment
at the first sign of mental illness.
59
Does depression increase the risk
for suicide?
The majority of people who have
depression do not die by suicide
Major depression does increase suicide
risk compared to people without
depression
60
Does depression increase the
risk for suicide?
The risk of death by suicide may be
related to the severity of the depression
About 2% of persons ever treated for
depression in an outpatient setting will die
by suicide
Among those ever treated for depression
in an inpatient hospital setting, the rate of
death by suicide is twice as high (4%)
61
Does depression increase the
risk for suicide?
Those treated for depression as inpatients
following suicidal ideation or suicide
attempts are about three times as likely to
die by suicide (6%) as those who were
only treated as outpatients
62
Gender Differences
There are significant gender differences in
lifetime risk of suicide in depression
7% of men with a lifetime history of
depression will die by suicide
1% of women with a lifetime history of
depression will die by suicide.
63
”Suicide Contagion"
Exposure to suicide or suicidal behaviors
within one's family, peer group, or through
media reports of suicide
Can result in an increase in suicide and
suicidal behaviors
64
Contagion
Direct and indirect exposure to suicidal
behavior has been shown to precede an
increase in suicidal behavior in persons at
risk for suicide, especially in adolescents
and young adults.
The risk for suicide contagion as a result
of media reporting can be minimized by
factual and concise media reports of
suicide
65
Contagion
Reports of suicide should not be
repetitive, as prolonged exposure can
increase the likelihood of suicide
contagion
Family members, friends, peers, and
colleagues of the victim should be
monitored and possibly evaluated by a
mental health professional
66
Do school-based suicide awareness
programs prevent youth suicide?
Few programs have been evaluated to see if they
work
Of the programs that have been evaluated, none has
proven to be effective
Some programs have had unintended negative effects
by making at-risk youth more distressed and less likely
to seek help
These programs present suicide as an option and
‘normalize’ it
67
Is it possible to predict suicide?
No definitive measure to predict suicide or
suicidal behavior
Factors can identify individuals at higher
risk for suicide
Very few persons with these risk factors
will actually commit suicide
68
Prediction
Risk factors include mental illness,
substance abuse, previous suicide
attempts, family history of suicide, history
of being sexually abused, and impulsive or
aggressive tendencies
Suicide is a relatively rare event and
difficult to predict statistically
69
What to do...
Promote overall mental health among schoolaged children by reducing early risk factors for
depression, substance abuse and aggression
Detect youth most likely to be suicidal by
confidentially screening for depression,
substance abuse, and suicidal ideation
If a youth reports any of these, further
evaluation takes place by professionals,
followed by referral for treatment as needed 70
Treatment Strategies - Meds
Antidepressants
Cyclic antidepressants including tricyclics.
MAO inhibitors
SSRIs
71
Treatment Strategies - Therapy
Psychodynamic /Interpersonal
Psychotherapy
Behavior Therapy
Cognitive Behavior Therapy (CBT)
Electroconvulsive Therapy (ECT)
72
Attempted Suicides
No annual national data on attempted
suicide are available; reliable scientific
research, however, has found that:
There are an estimated 8-25 attempted
suicides to one completion; the ratio is
higher in women and youth and lower in
men and the elderly
73
Attempts
More women than men report a history of
attempted suicide, with a gender ratio of
3:1
The strongest risk factors for attempted
suicide in adults are depression, alcohol
abuse, cocaine use, and separation or
divorce
74
Attempts
The strongest risk factors for attempted
suicide in youth are depression, alcohol or
other drug use disorder, and aggressive or
disruptive behaviors
75
Risk of Suicide Attempt
 3% Overall
 22% children with major depression
 25 % in those with substance abuse or
dependence.
with two or more disorders, the rate of
suicidal ideation was eight times higher
than normal,
rate of suicide attempts was 18 times
higher than normal.
76
Findings
Substance abuse or dependence is
specifically related to suicide attempts
Substance abuse appeared to play a key
role in the transition from suicidal thoughts
to actual suicide attempts.
Certain psychiatric symptoms raise the
risk of suicide.
77
Time for Your Questions
78