©AMSP Suicidal Behavior, Alcohol, and Alcohol Use Disorders Timothy W. Lineberry, M.D. Assistant Professor, Psychiatry Mayo Clinic

©AMSP US Prevalence Suicidal Behavior %/yr#/yr Thoughts3.39,900,000 Attempts 0.6 (4.6 Lifetime) 1,800,000 (13,800,000) Suicide~ 0.01>32,000

©AMSP %/yr (Lifetime) #/yr (Lifetime) Hazardous2575,000,000 Abuse 5 (18) 15,000,000 (54,000,000) Dependence 4 (13) 12,000,000 (39,000,000) US Prevalence Alcohol Use Disorders

©AMSP This Lecture will Cover Definitions Relationship Screening & identification Assessment & management

©AMSP 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

©AMSP 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

©AMSP 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

©AMSP 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

©AMSP 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

©AMSP Suicide-related Behavior Ideation = thoughts of Attempt = deliberate self-harm Completion = death from attempt

©AMSP This Lecture will Cover Definitions Relationship Screening & identification Assessment & management

©AMSP Alcohol Use Disorders and Suicide Alcohol use disorders Suicide ~25%

©AMSP Alcohol Dependence and Suicide Suicidal ideation ↑ 3-5X Suicide attempts ↑ 4-6X Lifetime suicide rate 7-10%

©AMSP 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%

©AMSP Depression and suicide Depression Suicide ~40%

©AMSP Which came First? 80% of patients with alcohol dependence report lifetime depressive symptoms Sustained heavy alcohol use induces depressive symptoms

©AMSP “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

©AMSP 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

©AMSP Alcohol Dependence and MDD MDD Alcohol Dependence Alcohol Induced 26% Independent 15%

©AMSP 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

©AMSP Major Depression Suicide- related behaviors Alcohol use disorders Alcohol Use Disorders are Related to Suicide

©AMSP This Lecture will Cover Definitions Relationship Screening & identification Assessment & management

©AMSP 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

©AMSP 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

©AMSP Evidence Based Screening Screening ≠ diagnosis Screening tools include – History – Survey – Physical exam – State markers (laboratory) + Screen requires full evaluation

©AMSP CAGE Cut down, Annoyed, Guilt, Eye- opener Positive test > 2 yes answers Sensitivity → 50-80% Specificity → ~ 80% Doesn’t screen for hazardous drinking

©AMSP AUDIT 10-item survey Developed by W.H.O. Score of > 8 = positive test for hazardous drinking/ ↑ chance of alc. dx Sensitivity → ~70% Specificity → 80% 3-item survey Sensitivity/specificity = to 10-item AUDIT Positive score –Men > 4 –Women ≥ 3 AUDIT-C

©AMSP Physical Examination  3 drinks/day  risk of hypertension Hepatosplenomegaly (liver/spleen size  ) Peripheral neuropathy: 15% w/alc dep

©AMSP 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)

©AMSP 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

©AMSP This Lecture will Cover Definitions Relationship Screening & identification Assessment & management

©AMSP Manage At Risk Patients  Positive screen  History, survey, physical exam, state markers  Full evaluation  Use diagnostic criteria  Evidence-based treatments

©AMSP Define MDD in Alcohol Use Timeline interview Carefully assess lifetime MDD sxs Sxs present w/sustained abstinence? Family history of depression?

©AMSP Evidence Based Treatments Motivational Interviewing Cognitive Behavioral Therapy Disulfiram Naltrexone Acamprosate

©AMSP SAFE-T Suicide Risk Assessment Risk factors Protective factors Suicide inquiry Assess risk & level of care Document

©AMSP  Intent  Plan  Suicidal ideation  Thoughts of death  Hopelessness Stepwise assessment ©AMSP

©AMSP Assess Risk and Level of Care Clinical judgment Low risk → outpt follow-up Moderate → psychiatry/ER High → hospitalization

©AMSP Summary Definitions Relationship Screening & identification Assessment & management