Suicide and addiction

DEFINITION: Addiction is associated with suicidal behavior more frequently than mood disorders and schizophrenia. Addiction also increases social problems and mental health issues associated with suicide attempts and suicides. The complex relationship between addiction and suicide must be better understood to improve treatment outcomes for substance use disorders and suicide prevention programs.

Suicidality

Suicide is a serious public health problem and a leading cause of death among individuals who abuse substances and among persons who are chemically dependent. Those who heavily use substances are more likely than the general population to die by suicide. The risk of suicide increases as substance use progresses into abuse and addiction. Around one in five individuals who take their own lives have a substantial amount of alcohol in their system at the time of their death.

Addiction is a primary contributor to suicide risk. The risk of suicide attempts is highest among people who use amphetamine, methamphetamine, and cocaine; many suicide attempts are associated with alcohol abuse because more people consume alcohol. Determining the primary substance of an issue can be difficult because individuals who use substances often use multiple substances in combination. Individuals who use multiple substances are more likely than those who use only a single substance to engage in suicidal ideation or thoughts about taking their own life.

Suicidal ideation is a predictor of suicide among individuals who abuse substances. People with substance use disorders (SUDs) who have thoughts about attempting suicide are more often depressed, take more health-related risks, and show more aggression than individuals who use substances who have not thought about suicide. Suicidal ideation often occurs during the “crash” or withdrawal, in which the pleasurable effects of a drug give way to agitation and depression, increasing the risk of suicide.

The relationship between suicide and substance abuse is complex. Suicide and substance abuse are not consequences of a single cause. They are behavioral outcomes resulting from the interaction of multiple stressors. The risk factors that contribute to suicide can also contribute to substance abuse.

Risk Factors

Factors associated with increased risk for suicide and addiction often overlap and include childhood abuse or trauma, sexual abuse, poor family relationships, poor communication and interpersonal conflict, family psychiatric history, unemployment and financial stress, biological correlates, impulsivity, hopelessness, previous suicide attempt, history of violence, and mental health problems including depression, bipolar disorder, and generalized anxiety disorder.

Substance abuse increases the risk of suicide by affecting cognition, mood, and impulsiveness. Substance abuse impairs judgment, increases affective instability, and reduces inhibition. This makes self-directed aggression more likely, particularly for people who have access to firearms or other means of suicide. Substance-related suicide attempts are more likely to have an impulsive component and to occur during a short-term crisis, during stress, or following a loss.

Most people with an SUD who attempt suicide have a comorbidity, or the presence of more than one disorder that coexists with a primary disorder but may be unrelated. Depression, anxiety, attention deficit hyperactivity disorder, obsessive-compulsive disorder, bipolar disorder, or other mental health problems often coexist with a SUD. The presence of untreated mental health conditions with SUD contributes to suicidal behavior.

It is not uncommon for persons with a psychiatric condition to self-medicate with drugs or alcohol. If the person enters a treatment program or abstains from substance use, then the effects of the illness can escalate, creating stress and contributing to suicide risk. Effective prevention and treatment programs take a holistic approach, focusing on treating underlying mental health condition(s) and SUD together, especially among those who use multiple substances because they are more likely to die by suicide than other individuals with a SUD.

Treatment

Treatment of addiction is an important part of a comprehensive approach to suicide prevention. Addiction counselors need to know how to screen for suicide risk and assess the risk of suicidal danger. Examples of screening and assessment tools include the Modified Mini Screen (MMS), which is used to identify anxiety, mood, and psychotic spectrum disorders, and the Addiction Severity Index (ASI), which is designed to assess seven factors contributing to substance abuse. Other helpful assessments include the Patient Health Questionnaire (PHQ) and the Columbia-Suicide Severity Rating Scale (C-SSRS). These tools help guide treatment plans and understand an individual's risk of suicide. To understand an individual's SUD and assess suicide risk, more than one assessment is sometimes necessary.

Evaluating the risk for suicide in a patient who has a substance use disorder is not easy. The patient may not be able to remember the details of a suicide attempt. It may also be difficult to establish that the patient intended to attempt suicide, as in the case of an overdose, which may appear to have been accidental. The difficulty in assessing and evaluating risk for suicide in addiction treatment programs and a lack of knowledge about the correlation between addiction and suicide have resulted in moving patients out of addiction treatment programs and into the mental health system. This places suicidal patients at greater risk for self-harm because the addiction, which is a primary contributor to suicide risk, is no longer being treated. To improve outcomes for persons with SUDs, suicide prevention programs should include addiction treatment programs.

Patients who are in treatment for SUDs and have attempted suicide report more psychiatric illnesses and more problematic SUDs than other patients. These patients benefit from inpatient treatment and increased intensity of care during the early phases of treatment. Motivational interviewing, which helps the patient understand the problems and consequences of substance abuse, continuing care, and psychosocial therapy, which focuses on improving communication skills and interactions a patient has with family and friends, has also contributed to improved treatment outcomes for persons with SUDs and a history of suicide attempts. Effective strategies for suicide prevention include restricting access to firearms and other means of suicide, gatekeeper training to enhance communication and intervention skills, public education campaigns, crisis hotlines, physician training, addiction treatment programs, and controlling the availability of drugs and alcohol.

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