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Suicidal Behavior and
Adolescent Substance
Use/Abuse
Oscar Bukstein, MD, MPH
Medical Director
Disclosure
• Royalties from Routledge Press
Objectives/Agenda
• What About Suicide and Substance
use disorders (SUDs)?
–Nature of relationship
• Screening, assessment
• Safety planning
• Treatment
And where did you learn all this, Dr. Bukstein?
• Service for Teens at Risk (STAR Center)
University of Pittsburgh Medical Center
Western Psychiatric institute and Clinic
Dr. David Brent
Dr. Mary Margaret Kerr
Why is it important to assess suicidal risk
and behavior?
• Suicide is the 3rd leading cause of death in
adolescents
• Suicide attempts are one of the most common
causes for psychiatric hospital admission in
this age group.
• Suicidal thoughts and actions often pre-sage
subsequent suicide attempts and completions
• Adolescents with SUDs have many suicide risk
factors and have a higher suicide risk
Since 1960…..
• Rapid increase in adolescent drug use
• 300% increase in suicidal behavior
–Increase between 1960-1990
• Attributable to drug and alcohol
problems
Morbidity & Mortality in Adolescence
Primary sources of death/disability are related to
problems with control of behavior and emotion
• Accidents, suicide, homicide, depression, alcohol &
substance use, violence, reckless behaviors, eating
disorders, risky sexual behaviors…
• Risk-taking, sensation-seeking, and erratic
(emotionally-influenced) behavior
• Onset of problems with later health consequences
Fundamental Imbalance in Puberty
• Rapid physical, endocrine, and social changes that
create early affective motivations and challenges
• Gradual, later development of affect regulation and
maturation of cognitive/self-control skills
Emotional Capacity
Pubertal drives and emotions;
sensation seeking; risk taking;
sensitivity to rewards, low self
control
Cognitive Capacity
Planning; logic; reasoning,
inhibitory control; problemsolving skills; capacity for
understanding long-term
consequences of behavior
The Adolescent Brain
Particularly vulnerable to external inputs:
• Environmental exposures
• Psychosocial stressors
• Drug and alcohol use
• Protective factors
Prefrontal cortex not fully developed until early adulthood
• Unique stage of change in metabolism, pruning, and
increased efficiency in prefrontal function
Emotional centers (limbic) without checks and balances
• Greater sensitivity to rewards, less inhibition
• Seek altered states of consciousness
Effects are longstanding
Breakdown in Brain’s Regulatory System May
Heighten Risk
Regulatory neural circuitry b/t prefrontal
cortex and limbic system vulnerable to:
• genetic defects
• developmental delays
• injury
• metabolic errors
• stress and adversity
• drug and alcohol use
Focal Point: Prefrontal Deficits
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Inability to accurately interpret social cues
Permits negative emotions to dominate
Heightened sensitivity to rewards (immediate)
Impulsivity and Inattention
Insensitivity to Consequence
* Doesn’t fully connect until after
adolescence!!!
Substance Use and Decision-Making
• Presumably substance use involves poor decision making
• Decision-making is determined by the interaction of higher
level brain processes
– Executive Functions
– Controlled largely by Pre Frontal Cortex (PFC)
• With lower level centers
– Limbic system - amygdala, hippocampus
– Nucleus Acumbens
What about Pre-existing “Brain” Problems
• PFC/Executive Functioning deficits: ADHD
– Increased prevalence in adolescents with SUDs/AUDs (up
to 50%)
– ADHD as SUD risk factor?
• Conduct problems (up to 80%)
– Definitely as risk factor
• Internalizing problems (more than half)
– Depression, , irritability, and anxiety
• Genetic Origin?
Confluence of Risk Factors
Suicide in 23 adolescent suicides compared to 12 community
controls with a lifetime history of substance abuse
• Suicides were more likely to be active substance abusers
• Have comorbid major depression,
• Suicidal ideation within the past week
• A family history of depression and substance abuse
• Legal problems
• Presence of lethal weapons in the home
• Bukstein et al., 2003
Suicide and SUDs in Adolescents
• Adolescent substance users have more than a 2.5-fold
increase in risk for suicidal behaviors compared to non-drug
using adolescents (SAMHSA, 2002).
• Combination of poor impulse control, stressful life events,
suicidal behavior, and substance use may interact to amplify
the likelihood of negative consequences that occur with these
behaviors (Bridge et al. 2006; Dalton et al. 2005; Putnins,
1995).
Impulse Control, SUDs, and Suicide
• Impulse control as a risk factor for SUDs
• Impulse control as a risk factor for
suicide
Stressful Life Events
• Risk factor for suicide
– Parental separation, social isolation; poor family
communication, family dysfunction; relationship breakups, conflicts with peers or parents; victimization by peers;
low social support, as well as relationship strain due to
parental SUD and other parental psychopathology
• Risk factor for SUDs
– See above
Acute Pharmacologic Effects of drug/aclohol
Intoxication
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Impair judgment
Lower inhibitions
Worsen impulse control
Affect specific neurotransmitter
systems
• Chronic neurocogntive effects
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Mann et al., 2003
SUD-Related Consequences
• Developmental problems/failures
–Academic
–Vocational
–Relationships
• Legal problems
Stress-Diathesis Model of Suicide
• Confluence of stressors and other risk factors interacting with
underlying predispositions or vulnerabilities (i.e. diatheses).
General Principles of Suicide Risk
Assessment
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Assessment is the beginning of treatment
Explain what you are going to do and why
Get the teen’s buy-in– ask permission!
Ask open-ended questions that cannot be
answered “yes” or “no.”
• Monitor the quality of information based on
consistency with other information obtained
and with non-verbal behavior
Assessment of Suicidal Behavior
• ID Risk factors
• Asking about Suicidal behavior
Five Key Domains of Risk Assessment*
“Risk Factors”
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Present/past suicidal ideation/behavior
Psychiatric disorders
Psychological traits
Family and environmental stressors and
supports
• Availability of lethal agents
*Brent et al. , 1997, 2001
Suicide: Distal Risk Factors
• Suicide history, personal or family
• Abuse
• Difficult course
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Difficult patient
Aggression
Depression
Substance Abuse
Proximal Risk Factors for Suicide
• Agitation, anxiety, akathisia
• Insomnia
• Despondent mood – “psychache”
• Ideation with intent
• Lability – mixed state, psychosis
• Lethal agents
Recognize Health Risk Behaviors Associated
with Suicidal Behavior*
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Unprotected sex and STDs
Alcohol, drug, tobacco use
Weapon-carrying
Binge eating and obesity
Bullying/being bullied
Each of these can in turn increase risk of
suicidality, accident, injury, and death
• LGBT
*King et al., 2001; Marshall et al., 2008
1.Characteristics of Suicidality*
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Intent/current ideation
Reasons for Living
Lethality
Precipitant
Motivation
*Hawton et al., 1982; Brent et al., 1997, 2001
Suicidal Behavior during Substance Use
• SB during intoxication
• SB during recovery (detox /or
withdrawal)
• SB related to SUD consequences
–Stressful life events
–Psychosocial failure
–Chronic neurocognitive changes
2. Psychopathology
• mood disorder, esp bipolar disorder,
particularly mixed state
• Substance abuse
• Conduct disorder
• Eating disorders
• PTSD, panic, complicated grief
• Comorbidity, chronicity, severity
• Developmental interactions (intent,
alcohol)
3. Psychological Characteristics
• Hopelessness (dropout, poor treatment response,
attempt)
• Impulsivity and aggression (strong predictor of earlyonset suicidal behavior, especially in presence of a
mood disorder, familial component)
• Distress tolerance/emotion regulation
• Social skills deficits (assertiveness, social problemsolving)
• Lack of Access to Positive Memories / Affect (Overgeneral Autobiographic Memory)
4. Family and Social Risk Factors
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Parental history of psychiatric illness suicidal behavior
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Abuse and neglect, in child and in parent
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Parent/child discord
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Disruption of interpersonal relationships
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Grief (esp. complicated grief)
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Disconnection and “drifting” (Gould, 1996)
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Bullying/being a bullier (girls)
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Same sex attraction, transgendered (bullying, family
rejection)
Family and Social Protective Factors
• Parent-child connection
• High parental expectations
• Parental supervision and
availability
• School connection
• Religious affiliation
• Non-deviant peer group
5. Availability of Lethal Agents
• Guns
• Medications
• Drugs and Alcohol
Asking….
Hierarchical questioning
• Start with hopelessness, through death wish to ideation,
intent, plan, and past attempts
• History of past attempts: when, means, intent, did anyone
know
– Are you disappointed that you did not succeed?
COLUMBIA-SUICIDE SEVERITY RATING SCALE (C-SSRS)
Posner, Brent et al, 2009
On- going Inquiry – high risk every time
Definitions of suicidality*
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Thoughts of death
Passive death wish
Thoughts of suicide, no plan or intent
Thoughts of suicide, plan and/or intent
“Aborted” suicide—person stopped self
“Interrupted” suicide– stopped by other
*Posner et al., 2007
Definitions (continued)
• Suicide attempt: Intentional selfinjurious behavior with at least inferred
intent to die
• Suicide completion: Suicide attempt that
results in fatality
• Don’t use the term “gesture.” (threat
with a prop)
Developing a Treatment plan
• Chain analysis
• Assess required level of care – based on
functioning and estimated ability to
adhere to a safety plan
• Safety Plan – including securing lethal
agents
• Treatment plan that decrease risk and
increase protective factors
Chain Analysis
• Reconstruct events, thoughts, feelings
leading up to the suicide attempt
• “Freeze frame” (Wexler, 1991)
• Identifies precipitants, motivation,
intent, current reaction, reaction of
environment
• Identifies stressors and vulnerabilities,
in order to develop a treatment plan
From Chain Analysis to Safety Plan
• Avoid Precipitants: Don’t call girlfriend,
don’t drink
• Self-coping: listening to music, exercise,
meditation, avoid stressful discussion
• Reaching out: calling friend, talking with
parents
• Clinical contact: therapist, on-call
clinician, crisis line, ER
No-Suicide Contract
• No-suicide contracts ask youth to promise to stay
alive without telling them how to stay alive
• •No-suicide contracts may provide a false sense of
assurance to the clinician
• No-suicide contracts have not been shown to
prevent recurrent suicidal behavior
• Instead, need a more dynamic contingency plan for
coping with suicidal thoughts and anticipated
stressors
What is a Safety Plan?
• Prioritized written list of coping strategies
and resources for use during a suicidal crisis
• •Provides a sense of control/framework
• •Brief process
• •Accomplished via an easy-to-read format
using the patient’s own words
• •Involves a commitment to the treatment
process (and staying alive)
Treatment Considerations
• Treat Depression, other mood and comorbid
disorders
– MDD, Bipolar disorder, ADHD
• Reduce Stress
– Family, social (peer), school issues
• Increase ability to handle stress
• Decrease “high risk” situations (including substance
use)
• Safety plan and automatic responses
• Decrease/stop substance use
Treatments for Adolescent with Suicidal Behavior
• Cognitive Behavior Therapy for Suicide Prevention (CBT-SP)
– theoretically grounded in principles of cognitive behavior
therapy, dialectical behavioral therapy and targeted
therapies for suicidal, depressed youth
– acute and continuation phases
– includes a chain analysis of the suicidal event, safety plan
development, skill building, psychoeducation, family
intervention, and relapse prevention.
– Drug and alcohol module to focus on role of D&A in mood
and suicidal behavior
Who Develops the Plan?
• Collaboratively developed by the clinician and the
youth in any clinical setting
• •Youth who have
-made a suicide attempt
-have suicidal ideation
-have psychiatric disorders that increase suicide risk
-otherwise been determined to be at high risk
for suicide
When is it Appropriate?
Usually follows a suicide risk assessment
• A safety plan may be done at any point during the
assessment or the treatment process
• Safety plan may not be appropriate when youth are
at imminent suicide risk or have profound cognitive
impairment
•The clinician should adapt the approach to the youth’s
needs—such as involving family members in using
the safety plan
Step 1: Recognizing Warning Signs
• Safety plan is only useful if youth can recognize the warning
signs
• •The clinician should obtain an accurate account of the
events that transpired before, during, and after the most
recent suicidal crisis
• •Ask ―How will you know when the safety plan should be
used?‖
• •Ask ―What do you experience when you start to think
about suicide or feel extremely distressed?‖
• •Write down the warning signs (thoughts, images, thinking
processes, mood, and/or behaviors) using the youths’ own
words
Step 2: Using Internal Coping Strategies
• List activities that youth can do without contacting another
person
• Activities function as a way to help youth take their minds off
their problems and promote meaning in the youth’s life
• Coping strategies prevent suicidal ideation from escalating
• It is useful to try to have youth cope on their own with their
suicidal feelings, even if it is just for a brief time
• Ask ―What can you do, on your own, if you become suicidal
again, to help yourself not to act on your thoughts or urges?‖
Step 3: Socializing with Family Members
or Others
• Coach youth to use Step 3 if Step 2 does
not resolve the crisis or lower the risk
• •Family, friends, and acquaintances who
may offer support and distraction from
the crisis
Step 4: Contacting Family Members or
Friends for Help
• Coach youth to use Step 4 if Step 3 does
not resolve the crisis or lower risk
• •Ask ―How likely would you be willing
to contact these individuals?‖
• •Identify potential obstacles and
problem solve ways to overcome them
Step 6: Reducing the Potential for Use of
Lethal Means
• Ask youth what means they would consider using during a
suicidal crisis
• •Regardless, the clinician should always ask whether the
patient has access to a firearm
• For methods of low lethality, clinicians may ask youth to
remove or restrict their access to these methods themselves
• -For example, if youth are considering overdosing, discuss
throwing out any unnecessary medication
• For methods of high lethality, collaboratively identify ways
for a responsible person to secure or limit access
How to negotiate about guns
• Are there guns at home? What kind? and how are they
stored?
• Who owns them?
• Ask these questions of the gun-owner):
– Why do you have them?
– Would you be willing to consider removing
them from the home for now?
– If not, would you be willing to secure them?
– Store ammunition elsewhere
Implementation: What is the Likelihood of
Use?
• Ask: ―Where will you keep your safety plan?‖
• Ask: ―How likely is it that you will use the Safety Plan when
you notice the warning signs that we discussed?‖
• Ask: ―What might get in the way or serve as a barrier to your
using the safety plan?‖
• -Help the youth find ways to
• overcome these barriers
• -May be adapted to brief crisis cards,
• cell phones or other portable
• electronic devices, must be readily
• accessible and easy-to-use.
Implementation: Review the Safety Plan
Periodically
• Periodically review, discuss, and possibly
revise the safety plan after each time it is
used
-The plan is not a static document
-It should be revised as youth’s
circumstances and needs change over
time
Follow up
Always follow up on plan
–Interim phone calls to family
–Other involved professionals
–Timely appointments
Document
Always Document!
What happened…
What you said…
Response of child/adolescent and family
Plan
Document
Always Document!
If it isn’t written down, it did not happen
What happened…
What you said…
Response of child/adolescent and family
Plan
Discussion