The Role of Alcohol and Substances in Suicide

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Q&A

Suicide Prevention Week is September 4-10. This week, we at Psychiatric Times want to highlight how best to support patients, friends, family, and anyone who might be having suicidal thoughts. We sat down with Manish Mishra, MBBS, the Chief Medical Officer of the Texas Healthcare and Diagnostic Center, to discuss.

PT: What does research say the role of alcohol/substances is in suicide?

Research on the link between alcohol and substances in suicide has been driven by the prevalent involvement of alcohol and substance abuse in suicide cases. There is a multitude of factors to be considered when examining the correlation between substance abuse and suicide as independent variables with an anecdotally strong interdependent relationship.

Historical data used to inform research suggests that across general populations, all types of substance abuse and substance use disorders are associated with increased risk for suicidal behaviors, including ideations, attempts, and fatalities. Substance abuse involving alcohol and illegal or prescription drugs is a much higher risk factor for suicidal mortality.

One of the reasons why alcohol and drug abuse is so strongly associated with suicide has to do with the psychological and psychosocial outcomes of untreated alcohol and drug dependence. Substance abuse and addiction often result in social isolation and marginalization, disruptions and conflicts in personal relationships, and aggravation of psychiatric symptoms such as depression and anxiety, all of which contribute to suicidal behaviors.

Another strong correlation is that alcohol and mind-altering substances are used as means of self-medication to cope with untreated mental health disorders, the symptoms of which are reciprocally exacerbated by substances. This causes a spiral effect of emotional decline and mental impairment that occurs with chronic alcohol and drug use and intoxication.

PT: People with alcohol use disorder are up 120 times more likely to commit suicide than those who are not dependent on alcohol.¹ Psychoeducation on substance use and suicide for patients and their families seems to be more important than ever. In your experience, what are the best strategies for clinicians to broach this subject?

The abuse of alcohol or drugs is one of the most common risk factors for suicidal behavior. Although this is a difficult way of intervention and requires significant involvement and commitment from both patient and family members, psychoeducation has been proven to be effective in treating mental health disorders and managing the prognosis in the long run. Different strategies are used by clinicians to assess and manage symptoms and avoid remission. Some of the strategies commonly used are as follows:

1) Brief intervention to reduce suicidal behavior

These types of interventions are mostly used with postdischarge patients for follow-up. It can include postcards, letters, or even a phone call. It helps in reducing the patient’s sense of isolation contributing to decreasing future suicidal behaviors.

2) Motivational enhancement techniques

Brief motivational enhancement techniques to increase patients’ willingness to pursue treatment and overcome obstacles may also be an effective engagement approach. Motivational interviewing is focused on helping people work through their ambivalence about changing their behavior and explores patients’ concerns and beliefs about change.

Most important to motivational interviewing is to engage patients in a discussion that is noncoercive and nonthreatening, and to create an atmosphere that is empathic, nonjudgmental, and supportive of the patients’ concerns. Open-ended questions, affirmations, reflective listening, and summarizing are the cornerstones of this approach.

3) Early intervention

Early intervention after a suicide attempt is vital because the 3-month period after an initial attempt is when an individual is at the highest risk of additional suicidal behavior. Yet those who attempt suicide have been found to be very difficult to engage in treatment. These interventions can include outpatient or inpatient treatment depending upon the severity. Postcards and phone calls can both be used for the outpatient approach, whereas motivational interviewing has been more effective with inpatient treatment.

4) Alternatives

This strategy provides for participation in activities that exclude alcohol, tobacco, and other drug use. Constructive and healthy activities offset the attraction to, or otherwise meet the needs usually filled by, alcohol, tobacco, and other drug use, which ultimately reduces suicidal tendencies.

PT: How can mental health clinicians improve the conversation surrounding this issue beyond the office?

Part of preventing suicide is raising awareness around the topic and bringing it into conversations. The topic of suicide is surrounded by secrecy, which is one of the barriers to getting treatment for people who need it. Mental health clinicians can play a part in dispelling the secrecy and stigma around suicide, and increase social empathy by discussing it as often and openly as other mental health issues are commonly verbalized.

As subject matter experts in their fields, mental health professionals have the capacity and agency to shed light on how prevalent suicidal behaviors actually are among general populations, and help to destigmatize suicide and associated mental health disorders. This stigma is a big reason why many people do not seek help for treatable mental health conditions and preventable tragedies.

PT: Global alcohol consumption has increased in recent decades, and is linked with more than 60 types of diseases and injuries.² Should clinicians be talking to patients about healthy alcohol consumption levels, or even abstinence?

Many people who drink to excess would not categorize themselves as being alcoholics or having an alcohol use disorder. Many would also not consider broaching the subject to a clinician if they think it would be irrelevant, or they do not want to be labeled as someone with an alcohol problem. Clinicians are responsible for informing their patients of the dangers and risks associated with excessive alcohol consumption, including binge drinking and chronic intoxication, as a preventative protocol—not only as a response to an immediate health concern.

Even if someone does not fit all the criteria of an alcohol use disorder, they can still be at risk of developing alcohol dependence, putting their physical and mental health at risk due to alcohol abuse. Addressing alcoholism in a clinical setting and providing recommendations about setting limits or considering abstinence can help people make informed and conscientious decisions about their alcohol consumption.

PT: When devising a safety plan with patients, how do you discuss substance use?

Safety planning is a brief intervention to help individuals survive suicidal crises by having them develop a set of steps to reduce the likelihood of engaging in suicidal behavior. Safety planning is frequently included as an element in cognitive behavioral interventions for suicide prevention and can also be used as a brief standalone intervention, typically paired with a referral for mental health treatment.

The role of the substance abuse treatment program is to provide safety for its clients: recognizing suicidality when it appears, having policies and procedures for addressing suicidal thoughts and behaviors, and ensuring that treatment for the substance use disorder is not lost in the suicidal crisis. A Treatment Improvement Protocol (TIP) developed a protocol, with the acronym GATE for discussing suicidality in patients with substance abuse. It is comprised of the following steps:

• Gather information.

• Access supervision or consultation.

• Take action to ensure appropriate care and safety for the client.

• Extend the action beyond the immediate situation to promote ongoing treatment and safety.

PT: Why is it important for clinicians to be talking about alcohol, substance use, and suicide with teenagers and young adults specifically?

Studies have observed that people who start abusing alcohol and drugs in early adolescence greatly increase their risk of developing mental health disorders and suicidal behaviors during adolescence or later on in their adult lives.³ Teenagers and young adults can benefit from being made aware of the risks associated with alcohol and mind-altering substances, and how even recreational use can adversely affect their mental health and increase the risk of suicide.

Raising awareness in these age groups about the severe consequences of substance abuse and chemical dependence requires a clinical approach to young, impressionable minds that are still developing. Adolescents are exposed to a lot of misinformation and skewed perceptions of drug culture through social media and society in general. It is critical to provide them with accurate information through a lens of empathy and compassion.

PT: Finally, what resources would you recommend to clinicians that might be good to share with patients?

Three elements that are key to identifying and addressing suicidal thoughts and behaviors among individuals in substance use treatment are:

1. Screening and assessment

2. Safety planning, including lethal means counseling (ie, assessing the individual’s access to firearms, medications, or other potentially fatal substances or objects)

3. Linkage to care

Here are a few methods and resources that can be used by clinicians which might be good to share with patients:

• Community reinforcement and family training (CRAFT)
• Medication
• Cognitive behavioral therapy (CBT)
• Online resources such as motivational interviewing, inspiring stories, or videos
• Inpatient treatment or rehabilitation
• Support groups

The following are some generalized resources on substance abuse and suicide that can increase awareness and educate patients and their loved ones:

• Man Therapy
• National Action Alliance Suicide Prevention Outpatient Health Care Self-Assessment
• Stanley Brown Safety Plan by the Suicide Prevention Resource Center (SPRC)
• Understanding Risk and Protective Factors for Suicide by the SPRC
• Preventing Suicide: a community engagement toolkit by the SPRC

Providing patients with resources is an opportunity that clinicians should use to empower patients to take initiative in maintaining and protecting their mental health. Patients are often unaware of the resources available to them and are more likely to use them if they know where to look.

Dr Mishra is the Chief Medical Officer of the Texas Healthcare and Diagnostic Center, and a medical reviewer for Ohio Recovery Center, where he works to provide accurate, authoritative information to those seeking help for substance abuse and behavioral health issues.

References

1. Alcohol and suicide. Alcohol Rehab Guide. Accessed August 24, 2022. https://www.alcoholrehabguide.org/resources/dual-diagnosis/alcohol-and-suicide/

2. Pompili M, Serafini G, Innamorati M, et al. Suicidal behavior and alcohol abuse. Int J Environ Res Public Health. 2010;7(4):1392-1431.

3. Wilcox HC. Epidemiological evidence on the link between drug use and suicidal behaviors among adolescents. Can Child Adolesc Psychiatr Rev. 2004;13(2):27-30.