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Transcript of Suicide and Alaska- some special topics Richard Ries MD [email protected] Harborview Medical...
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Suicide and Alaska-some special topics
Richard Ries MD
[email protected] Medical Center and
the University of WashingtonSeattle, Washington
RRies Addiction and Suicide
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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
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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
Some Facts about Suicide:
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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
Facts about Suicide:
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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
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USA Number ofSuicide Deaths
PopulationCrudeRate
Age-AdjustedRate**
36,909 307,006,550 12.02 11.77
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
Alaska 143
698,473 20.47 19.39
143 698,473 20.47
Idaho
3041,545,801 19.67 20.42
304 1,545,801 19.67
Washington 921
6,664,195 13.82 13.38
921 6,664,195 13.82
Oregon 644
3,825,657 16.83 16.11
644 3,825,657 16.83
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HOW U.S. SOLDIERS DIECombat
3%Undetermined
1%Homicide
4%
Illness25%
Suicide17%
Accident50%
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
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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.
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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
What about Addiction and Suicide ?
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Alcohol strongest predictor of completed suicide over 5-10 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)
Is Suicide also Addictions Territory?
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Modality Percents
2%
28%
9%39%
IPOPMMDetox
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25%20% 18% 20%
17%13% 11% 13%
0%
10%
20%
30%
40%
IP OP MM Detox
% Thoughts % Attempted
Lifetime Suicide Thoughts/Attempts
N=60,952
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8% 5% 4%9%
2% 1% 1% 2%0%
10%
20%
30%
40%
IP OP MM Detox
% Thoughts % Attempted
Past 30 days Suicide Thoughts/Attempts
N=60,952
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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 do we know about Suicide Attempts in Prospective Age-Matched Alcoholic
Populations
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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
What Predicted Suicide Attempts in Alcoholics (n=1,237) over 5
years?
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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.
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Su
icid
e in
Men
Su
icid
e in
Wo
men
Men Women Alcohol Consumption
Standardized suicide mortality rates in men and women with mean annual alcohol consumption in liters per capita.
Russia 1965-99.
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Su
icid
e R
ates
per
100
,000
Alc
oh
ol
con
sum
pti
on
BAC Positive Suicides
BAC Negative Suicides
Alcohol Consumption
Mean annual consumption with BAC-positives and BAC-negatives for 8 Russian Regions 1981-1990.
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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 substance-induced mood disorder.
Pages K et al (1997)- Higher degrees of Sub Dep related to higher severity suicide ratings
Substance Induced Depression: Severity/Dangerousness
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METH ADDICTS: LIFETIME SUICIDE ATTEMPTS, BEHAVIOR PROBLEMS, AND FELONY CHARGES, BY GENDER
ASI ItemASI Item OverallOverall MalesMales FemalesFemales Test Test Statistic*Statistic*
Attempted Suicide (%)Attempted Suicide (%) 27%27% 13%13% 28%28% 35.42**35.42**
Violent behavior problems (%)Violent behavior problems (%) 43%43% 40%40% 46%46% 3.29***3.29***
Assault Charges (mean number)Assault Charges (mean number) 0.290.29 0.460.46 0.150.15 4.46**4.46**
Weapons charges (mean number)Weapons charges (mean number) 0.130.13 0.210.21 0.070.07 4.09**4.09**
*Mantel-Haenszel chi-square was used to test differences in proportions by gender, df=1; *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 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. continuous dependent variables reflecting the number of charges, df=1013.
**p < 0.00001 ***0.1 **p < 0.00001 ***0.1 << p <0.05 p <0.05Zweben, et al., 2004
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DoDo Anti-depressants treat OR decrease “Anti-depressants treat OR decrease “SuicidalitySuicidality”?”?
Am J Psychiatry. 2003 Apr;160(4):790-Am J Psychiatry. 2003 Apr;160(4):790-2. 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 antidepressant- and placebo-treated depressed subjects in controlled trials or a difference between SSRIs and either other types of antidepressants or placebo.
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Cohort suicide attempts
Adults Year Prior Year After> 25 yo (n=3524) 23%...........................4%18-24 yo (N=651) 28%...........................4%
Adoles (n=236) 23%...........................7%
Karageorge: National Treatment Improvement Evaluation study 2001
Can addiction treatment affect suicidality?
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Alcohol Consumption, Alcoholics Anonymous membership, and Suicide MortalityRates, Ontario, 1968-1991.Mann RE, Zalcman RF, Smart RG, Rush BR, Suurvali H.
Method: We studied the impact of alcohol consumption levels, AA membershiprates, and unemployment rates on suicide mortality rates in Ontario from 1968 to1991. 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).
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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
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Overdose Planned Overdose Planned LethalityLethality
Fully accidental
Just blot out worries
Who cares if I wake
Lethal Plan
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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”
Opioid Deaths
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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
Suicide and Opiates
Harris and Barraclough, 1997; Darke and Ross, 2002, Ries SPOT unpub
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Risk Factors for Suicide in Opiate Abusers Parallel Risk Factors for Accidental Overdose(Darke and Ross, 2002)
AccidentalOverdose
Suicide
Male gender
DepressionPreviousattempt
Previousoverdose
Personality Disorder: CCD ASPD
Hx. of childhoodsexual trauma
Homelessness Social isolation
Poly-substance abuseGenetic predisposition
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Prevention of Fatal overdose 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
Evidence Supported Overdose Prevention
Programs
Gunne and Gronbladhm, 1981; Bammer, 2000; McGregor, Ali Christie, Darke, 2001
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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
Preventing Addiction Related Suicie (PARS)
NIDA R21Ries, Voss, Comtois,
Addictions staff and directors
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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 YES94%
(n=59)6%
(n=4)1-month follow-up
78% (n=49)
22% (n=14)
P=.009
Pilot Data PARS In the past 30 days, have you asked for help because you were having suicidal thoughts/feelings.
Pre-test No97%
(n=60)
YES3%
(n=2)
1 month follow-up
90% (n=56)
10% (n=6)
P=.000
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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:
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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
Suicide Resources:
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Suicide Assessment
Suicide prevention
Suicide Treatment
Now lets talk about some of YOUR issues