Bagge, Courtney, L. and Borges, Guilherme. (2017). Acute substance use as a warning sign for suicide attempts: a case cross over examination of the 48 hours prior to a recent suicide attempt. Journal of Clinical Psychiatry, doi: 10.4088/JCP.15m10541. [Epub ahead of print].
As a Deployment Behavioral Health Psychologist for the Center for Deployment Psychology and a faculty member in a pre-doctoral Air Force Psychology Internship Program, I have ample opportunity to teach about warning signs and risk factors for suicide. I also have had plenty of patients and oversight of interns’ patients with substance use disorders, in particular alcohol use disorders. So, it is of particular interest to me to understand more fully the relationship between alcohol use (and other substance use) and suicide attempts.
A relatively recent focus in the field of suicide is that of risk factors (more distally associated with suicidal behavior) versus warning signs (more immediately associated with suicidal behavior). Some risk factors are not modifiable via treatment (e.g., history of childhood trauma) and some are modifiable (e.g., poor coping skills). Alcohol use is considered both a risk factor and a warning sign, and as the authors point out, the role of alcohol use as a risk factor is more understood and established than its role as a warning sign. Since alcohol use is clearly modifiable as a risk factor or a warning sign, understanding the role that alcohol plays in making suicide more or less likely is critical. This study sought to add to the field by deepening our understanding of alcohol as a warning sign and also providing information about specific categories of acute drug use on the likelihood of suicide attempt. In other words, this study aimed to understand the role that alcohol may play as a warning sign but also included other substances: cannabis, CNS depressants (sedatives, anxiolytics, opioids), and CNS stimulants (stimulants and/or cocaine).
Using a Timeline Followback Interview method, the researchers gathered information about life events including substance use in the 48 hours prior to a suicide attempt. Subjects were between 18 and 64 years old and were recruited from a Level 1 trauma hospital within 24 hours of a suicide attempt. The authors differentiated the day before the suicide attempt (the control day) and the day of the suicide attempt (the case day) and found that alcohol was the substance most commonly used with other substances on both control and case days. Statistical analyses revealed these findings among others: the presence of any alcohol use, CNS depressant use, or negative life events was associated with an increased risk of attempting suicide. On the other hand, the presence of cannabis use or CNS stimulant use was not associated with increased likelihood of attempting suicide. In fact, for individuals who used cannabis or stimulants only (not in conjunction with alcohol), the suicide rate may have been reduced. The finding that alcohol use is associated with an increased likelihood of suicide in a temporal context that is suggestive of a warning sign is consistent with other research suggesting the same. This study expanded on this, however, to point out that alcohol plays this role independent of other substance use. In addition, this study found that the use of alcohol with CNS depressants may act synergistically and that any reduced likelihood of suicide attempt seen with the use of cannabis or CNS stimulants alone may be negated by the co-use of alcohol. Another important finding included the observation of high rates of co-use of alcohol with other substances on the case day.
Given the above findings with regard to how alcohol impacts the likelihood of suicide and also alcohol impacts how other drugs affect the likelihood of suicide, the authors make recommendations. Specifically, they suggest that clinicians should educate patients about an increased risk of suicide attempt within 24 hours of drinking alcohol. In addition, prescribers should consider the findings from this study regarding their choice to prescribe CNS depressants (e.g., anxiolitics), especially among patients who drink alcohol. When working with suicidal patients who drink alcohol and/or are prescribed (or use) CNS depressants, extra care should be given to discuss the increased risks with their use, especially in combination. In addition, safety planning should include details about the findings of this study, making it clear to patients that alcohol alone, or in combination with other drugs is likely to enhance the likelihood of a suicide attempt.
Regina Shillinglaw is a Deployment Behavioral Health Psychologist with the Center for Deployment Psychology located at Wright-Patterson Medical Center in Ohio.