What is the relationship between suicide and addiction?

Suicidality

Suicide is a serious public health problem and a leading cause of death among substance abusers and among persons who are chemically dependent. Heavy substance users are more likely than the general population to die by suicide. The risk of suicide increases as substance use progresses into abuse and addiction.

Addiction is a primary contributor to suicide risk. The risk of suicide attempts is highest among people who abuse amphetamine, methamphetamine, and cocaine; however, more suicide attempts are associated with alcohol abuse because more people consume alcohol. Determining a primary substance can be difficult because substance abusers often use multiple substances in combination. Multi-substance abusers are more likely than single-substance abusers to engage in suicidal ideation, or thoughts about taking one’s own life.

Suicidal ideation is a predictor of suicide among substance abusers. People with substance use disorders who have thoughts about attempting suicide are more often depressed, take more health-related risks, and show more aggression than substance abusers 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 one single cause. They are behavioral outcomes that result from a combination of interacting stressors. The risk factors that contribute to suicide also can 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.

Gender also may have a part in mortality rates from suicide. Female suicide mortality rates are strongly related to alcohol consumption. The social stigma and inaccurate stereotypes attached to women with drinking problems can contribute to guilt and shame and can serve to increase a woman’s sense of isolation and loneliness. The exacerbation of these feelings by alcohol use adds to the likelihood of suicidal ideation and suicide attempts, creating a history of suicidal behavior that, in turn, has been linked to later alcohol problems among women.

Among men, serious substance abuse and addiction are correlated with higher rates of completed suicides.

The majority of persons who attempt suicide suffer from comorbidity, or the presence of more than one disorder that coexists with a primary disorder but may be unrelated. Depression or other mental health problems, such as bipolar disorder, along with a substance use disorder may overlap and contribute to suicidal behavior.

It is not uncommon for persons with a psychiatric illness 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 in the user and contributing to suicide risk. Effective prevention and treatment programs need to focus on psychiatric disorders and addiction, especially among multi-substance abusers who are more likely to die by suicide than are single-substance abusers.

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, which is used to identify people who need a mental health assessment, and the addiction severity index, which is designed to assess factors contributing to substance abuse problems.

Evaluating the risk for suicide in a patient who has a substance abuse disorder is not easy. The patient may not be able to remember the details of a suicide attempt. It also may 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 has 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 substance use disorders, suicide prevention programs need to include addiction treatment programs.

Patients who are in treatment for substance use disorders and have attempted suicide report more psychiatric illnesses and more problematic substance abuse. 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, also have contributed to improved treatment outcomes for persons with substance use disorders 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.

Bibliography

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