Transcript Suicidal Behavior, Alcohol, and Alcohol Use Disorders

Suicidal Behavior,
Alcohol, and Alcohol
Use Disorders
Timothy W. Lineberry, M.D.
Assistant Professor, Psychiatry
Mayo Clinic
©AMSP 2008
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US Prevalence Suicidal Behavior
%/yr
#/yr
Thoughts
3.3
9,900,000
Attempts
0.6
(4.6 Lifetime)
1,800,000
(13,800,000)
Suicide
~ 0.01
>32,000
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US Prevalence Alcohol Use Disorders
%/yr
(Lifetime)
#/yr
(Lifetime)
Hazardous
25
75,000,000
Abuse
5
(18)
15,000,000
(54,000,000)
Dependence
4
(13)
12,000,000
(39,000,000)
©AMSP 2008
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This Lecture will Cover
• Definitions
• Relationship
• Screening & identification
• Assessment & management
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Hazardous Drinking
• Men  5 drinks/day or  15 drinks/week
• Women  4 drinks/day or  8 drinks/week
• “At risk” for  alcohol-related problems
• NOT alcohol abuse or dependence
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Alcohol Abuse
– 12-month pattern of problems in  1 of:
• Inability to meet obligations
• Physically hazardous situations
• Legal problems
• Social or interpersonal problems
– Not alcohol dependence
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Alcohol Dependence
• 12-month pattern of problems in  3 of:
– Tolerance:  use = same effect
– Withdrawal: Use to relieve/avoid withdrawal
– Use larger amounts/longer than intended
– Desire to or unsuccessful efforts to cut down
–  time spent in alcohol-related activities
– Give up important social activities
– Continued use despite persistent problems
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Major Depressive Disorder (MDD)
• MDD lifetime prevalence: ♀ 15%: ♂ 8%
• Must represent change in function
• Subjective report or observation of others
• > 5 symptoms nearly daily for 2-weeks
• Must have at ≥ 1 of following 2
1. Depressed mood most of the day
2. ↓ interest/pleasure in most activities
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Additional MDD Criteria
• Weight ↓ or ↑ or appetite ↓ or ↑
• Sleep ↓ or ↑
• Psychomotor agitation or retardation
• Fatigue or ↓ energy
• Feelings of worthlessness or inappropriate guilt
• ↓ Ability to think/concentrate or indecisiveness
• Recurrent SI or thoughts of death
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Suicide-related Behavior
• Ideation = thoughts of
• Attempt = deliberate self-harm
• Completion = death from attempt
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This Lecture will Cover
• Definitions
• Relationship
• Screening & identification
• Assessment & management
©AMSP 2008
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Alcohol Use Disorders and Suicide
Alcohol use disorders
~25%
Suicide
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Alcohol Dependence and Suicide
• Suicidal ideation ↑ 3-5X
• Suicide attempts ↑ 4-6X
• Lifetime suicide rate 7-10%
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Major Depression
• ~40% of suicides have MDD
• 20% with MDD attempt in lifetime
• Lifetime suicide rate varies with
severity of depressive illness
–Psych. hospitalized + SI:
9%
–Hospitalized without SI:
4%
–Outpt. depression:
2%
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Depression and suicide
Depression
~40%
Suicide
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Which came First?
• 80% of patients
with alcohol
dependence report
lifetime depressive
symptoms
• Sustained heavy
alcohol use
induces depressive
symptoms
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“Independent” MDD
• Predates alcohol dependence
diagnosis or occurs in times of
sustained abstinence
• More likely to have family history
of MDD
• 15% of alc dependence patients
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Alcohol Induced MDD
• Temporary sxs associated with use
–Typically resolve in ~ 4 weeks
• Resolve with sustained abstinence
• Family history of MDD less likely
• 26% of alc dependence patients
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Alcohol Dependence and MDD
Alcohol Dependence
MDD
Alcohol
Induced 26%
Independent
15%
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Depression + Alcohol Dependence
•  Suicide rate
• Independent depression ↑ suicide
attempt rate vs. alcohol induced
• Increasing age  risk for both
• Depression and alcohol use disorder
make up ~65% of all suicides
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Alcohol Use Disorders are Related
to Suicide
Major Depression
Alcohol use disorders
Suicide-related behaviors
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This Lecture will Cover
• Definitions
• Relationship
• Screening & identification
• Assessment & management
©AMSP 2008
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Ask Everyone!
• <25% patients routinely screened for alcohol use
• ~ 40% with MDD missed by primary MD
• 35% with known MDD asked about suicide
• MDs report discomfort with asking
• MDs miss obvious clinical patterns
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Patients Expect
• To be asked about alcohol use
• To be asked about emotional problems
• Guidance about use and risky behaviors
• Judge MD skill based on their attention to
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Evidence Based Screening
• Screening ≠ diagnosis
• Screening tools include
–
–
–
–
History
Survey
Physical exam
State markers (laboratory)
• + Screen requires full evaluation
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CAGE
• Cut down, Annoyed, Guilt, Eyeopener
• Positive test > 2 yes answers
• Sensitivity → 50-80%
• Specificity → ~ 80%
• Doesn’t screen for hazardous
drinking
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AUDIT
AUDIT-C
• 10-item survey
• 3-item survey
• Developed by W.H.O.
• Score of > 8 =
positive test for
hazardous drinking/ ↑
chance of alc. dx
• Sensitivity/specificity
= to 10-item AUDIT
• Positive score
• Sensitivity → ~70%
– Men > 4
– Women ≥ 3
• Specificity → 80%
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Physical Examination
3 drinks/day  risk of hypertension
Hepatosplenomegaly (liver/spleen size )
Peripheral neuropathy: 15% w/alc dep
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State Markers
• Blood tests
• Change with heavy sustained alcohol use
– Gamma-glutamyl transferase (GGT)
– Carbohydrate Deficient Transferrin (CDT)
– CBC w/Mean Corpuscular Volume (MCV)
– Aspartate transaminase (AST)
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2 Question Depression Screening
• In the past month…
1. Have you been bothered by feeling
down, depressed, or hopeless?
2. Have you been bothered by little
interest/pleasure in doing things?
• ≥ 1 yes = positive test
• Sensitivity: 96%; specificity: 57%
• Remember! screening ≠ diagnosis
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This Lecture will Cover
• Definitions
• Relationship
• Screening & identification
• Assessment & management
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Manage At Risk Patients
Positive screen
History, survey, physical exam, state markers
Full evaluation
Use diagnostic criteria
Evidence-based treatments
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Define MDD in Alcohol Use
Timeline interview
Carefully assess lifetime MDD sxs
Sxs present w/sustained abstinence?
Family history of depression?
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Evidence Based Treatments
• Motivational Interviewing
• Cognitive Behavioral Therapy
• Disulfiram
• Naltrexone
• Acamprosate
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SAFE-T Suicide Risk Assessment
Risk factors
Protective factors
Suicide inquiry
Assess risk & level of care
Document
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Stepwise assessment
Intent
Plan
Suicidal ideation
Thoughts of death
Hopelessness
©AMSP
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©AMSP
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Assess Risk and Level of Care
• Clinical judgment
• Low risk → outpt follow-up
• Moderate → psychiatry/ER
• High → hospitalization
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Summary
• Definitions
• Relationship
• Screening & identification
• Assessment & management
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