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Acute Alcohol Use Acute Alcohol Use and Suicide Attemptsand Suicide Attempts
Courtney L. Bagge, PhDCourtney L. Bagge, PhDUniversity of Mississippi Medical CenterUniversity of Mississippi Medical Center
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RatesRates Suicidal behavior is commonSuicidal behavior is common
> 36,000 die by suicide> 36,000 die by suicide
1010thth cause of death in US cause of death in US
5 attempts per suicide5 attempts per suicide
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RatesRates Alcohol use/misuse is commonAlcohol use/misuse is common
UseUseLifetime: 90%Lifetime: 90%Past year: 53% Past year: 53%
Misuse (lifetime)Misuse (lifetime)Abuse/problems: 15%Abuse/problems: 15%Dependence/alcoholism: 10%Dependence/alcoholism: 10%
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Use & AUD Overlap Use & AUD Overlap
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Clinical Case Clinical Case Primary care check-upPrimary care check-up
30 yr old female30 yr old female
Drinks 1-2 drinks every 2 mo.Drinks 1-2 drinks every 2 mo.
No suicidal thoughtsNo suicidal thoughts
No history of depression No history of depression
Mentions relationship prob.Mentions relationship prob.5
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Lecture will Cover Lecture will Cover DefinitionsDefinitions
RelationsRelations
Reasons for drinkingReasons for drinking
Prevention/Treatment Prevention/Treatment 6
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DefinitionsDefinitions Suicidal thoughts (ideation)Suicidal thoughts (ideation)
Thoughts of killing oneselfThoughts of killing oneself
Suicidal behaviorSuicidal behavior
Self-inflicted act (intent to die)Self-inflicted act (intent to die)
Suicide: Fatal outcomeSuicide: Fatal outcome
Attempt: Non-fatal outcomeAttempt: Non-fatal outcome7
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Alcohol: Standard DrinkAlcohol: Standard Drink
~10 gm pure alcohol ~10 gm pure alcohol
Beer: 12 oz.Beer: 12 oz.
Wine: 4 oz.Wine: 4 oz.
Spirits: 1.5 oz.Spirits: 1.5 oz.
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Alcohol: Drinking Alcohol: Drinking Patterns Patterns
Quantity frequencyQuantity frequency Heavy episodicHeavy episodic
5+ drinks/occasion ♂ 4+ drinks/occasion ♀
BingeBinge Intox. > 2 days Give up usual activities for intox.
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Alcohol Use DisordersAlcohol Use Disorders
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AbuseAbuse 1+ in same 12 mos:1+ in same 12 mos:
1.1. ↓ ↓ role obligationsrole obligations
2.2. Hazardous useHazardous use
3.3. Legal problemsLegal problems
4.4. Interpersonal problemsInterpersonal problems
dependencedependence
DependenceDependence 3+ in same 12 mos:3+ in same 12 mos:
1.1. ToleranceTolerance
2.2. WithdrawalWithdrawal
3.3. Use more Use more oror longer longer
4.4. Desire/inability to ↓Desire/inability to ↓
5.5. Other activities given upOther activities given up
6.6. ↑ ↑ obtain, use, recoverobtain, use, recover
7.7. Use despite problemsUse despite problems
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Acute Alcohol UseAcute Alcohol Use Any contextAny context
Acute alcohol: Acute alcohol: 1 drinking instance 1 drinking instance
When discussing attemptsWhen discussing attempts Acute alcohol: 1 Acute alcohol: 1 specific specific instanceinstance
Drinking prior to attempt Drinking prior to attempt (3-6 hrs)(3-6 hrs)
Drinking any alcoholDrinking any alcohol
Drinking to intoxicationDrinking to intoxication11
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Lecture will Cover Lecture will Cover DefinitionsDefinitions✔✔
RelationsRelations
Reasons for drinkingReasons for drinking
Prevention/Treatment Prevention/Treatment 12
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Descriptive Statistics Descriptive Statistics Drinking on day of attempt: 40% Subgroups differ
Men (53%) > Women (40%) < age 50 ↑ AUD
Design limitations Rates only descriptive Association not tested
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Case-Control Research Case-Control Research Who is likely to attempt suicide?Who is likely to attempt suicide? Compare 2 groups on alcohol useCompare 2 groups on alcohol use
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Not Exposed
Attempt No Attempt
“CASES” “CONTROLS”
Exposed
(Drink)
Exposed
(Drink)
Not Exposed
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Key Findings Key Findings Acute use (> 100 g): 60X risk Chronic use (>100 g/day): 3X risk Modeled together:
Acute use > effect (6X risk) Chronic use no longer ↑ risk
Design limitations No best control group Many case-control differences
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Case-Crossover Research Case-Crossover Research When is someone likely to attempt?When is someone likely to attempt? 1 person: Compare use in 2 periods1 person: Compare use in 2 periods
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Suicide Attempt
Case PeriodDay attempted
Control PeriodDay didn’t attempt
Drink? Drink?
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Key Findings Key Findings ↑ risk of suicide attempt while drinking
Regardless of sex, age, marital
Infrequent drinkers (< 1 mo) Acute drinking ↑ risk than others Clinical importance
3rd variable Time of day Place Situation
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EventEvent
AttemptAttemptDrinkDrink
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Lecture will Cover Lecture will Cover DefinitionsDefinitions✔✔
RelationsRelations✔✔
Reasons for drinkingReasons for drinking
Prevention/Treatment Prevention/Treatment 18
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Reasons for Drinking: Day of Reasons for Drinking: Day of Attempt Attempt Non-Suicide Related Reasons
Social, Enhancement, & Coping
Prevalence: 67% 60% no influence 40% impaired judgment
How increase risk? ↑ neg. mood, aggressiveness, impulsivity All or nothing thinking Alcohol myopia- attentional shortsight
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Reasons for Drinking: Day of Reasons for Drinking: Day of Attempt Attempt Suicide Related Reasons
To facilitate attempt (33%) As suicide method (26%)
How increase risk? ↑ courage Anesthetize pain of dying Alcohol poisoning Interaction with other substances
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Lecture will Cover Lecture will Cover DefinitionsDefinitions✔✔
RelationsRelations✔✔
Reasons for drinkingReasons for drinking✔✔
Prevention/Treatment Prevention/Treatment 21
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Docs likely contacted 1 mo prior Docs likely contacted 1 mo prior
Primary care doctor (45%)Primary care doctor (45%)
Mental health provider (20%)Mental health provider (20%)
Primary care: Many seek help Primary care: Many seek help
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Doc Visit: Unique Opportunity!Doc Visit: Unique Opportunity!
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Doc Visit: Unique Opportunity! Doc Visit: Unique Opportunity! Evaluate Evaluate bothboth
ScreenScreen MonitorMonitor PreventPrevent TreatmentTreatment
AskAsk all drinkers about suicide all drinkers about suicide Regardless of chief complaint Don’t be afraid to ask Not cause suicide, but ↓ risk
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Stepwise Progression: Ask Stepwise Progression: Ask alall ? l ? 1)1) EverEver thought about: thought about:
Death/dying?Death/dying? Life not worth living?Life not worth living? Ending life?Ending life?
2)2) Ever attempted suicide?Ever attempted suicide?3)3) CurrentCurrent thoughts? thoughts? If ideation +If ideation +
Ask frequency, duration, intensityAsk frequency, duration, intensity Plan and intentPlan and intent
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Docs: Ask Docs: Ask allall about alcohol about alcohol patterns patterns Alcohol Use Identification Test-CAlcohol Use Identification Test-C
Q1) Q1) Frequency of any use Frequency of any use 0 (Never) to 4 (4 or more X/week)0 (Never) to 4 (4 or more X/week)
Q2) Q2) # drinks/typical drinking day# drinks/typical drinking day 0 (None) to 4 (10 or more)0 (None) to 4 (10 or more)
Q3) Q3) Frequency of heavy episodic useFrequency of heavy episodic use 0 (Never) to 4 (almost daily or daily)0 (Never) to 4 (almost daily or daily)
Scoring 0-12 (screen ≠ diagnosis)Scoring 0-12 (screen ≠ diagnosis) AUD → Men > 4; Women > 3 Sensitivity: 80-90%; specificity: 60-70%
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Docs: Ask Docs: Ask why why patient drinks patient drinks Enhancement, social, to cope If cope: ↑ risk for suicidal thoughts Help find other coping strategies
How coped in past w/out alcohol? Talk to someone/Call friend Leave situation/Walk in park Distract self/Watch comedy
Docs remember: Don’t ignore Infrequent drinkers or not AUD
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Clinical Case Clinical Case Primary care check-upPrimary care check-up
30 yr old female30 yr old female No suicidal thoughtsNo suicidal thoughts No history of depression No history of depression Drinks 1-2 drinks every 2 mo.Drinks 1-2 drinks every 2 mo. No evidence of AUDNo evidence of AUD Mentions relationship prob.Mentions relationship prob. What else should we ask?What else should we ask?
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What happened to the patient? What happened to the patient?
Relationship break upRelationship break up
Attempted suicideAttempted suicide
Brought to ER-saidBrought to ER-said
Used alcohol for copingUsed alcohol for coping
Suicidal thoughts shortly before actSuicidal thoughts shortly before act
Drinking connected to attempt?Drinking connected to attempt?28
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Behavior Chain Analysis Behavior Chain Analysis Prevent future alc/suicide actsPrevent future alc/suicide acts Discuss recent alc/suicide episodeDiscuss recent alc/suicide episode1)1)Identify when problem startedIdentify when problem started2)2)Identify how vulnerable to problemIdentify how vulnerable to problem
Physical illnessPhysical illness Not taking medicationsNot taking medications Eating/sleeping too muchEating/sleeping too much Drug useDrug use Alcohol useAlcohol use
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Prompting Event: Relationship break-up
Think: never find anyone elseMood: 9Angry: 7Do: Drive to a bar
Suicide Attempt
VULNERABILITIES: staying up late, no lunch
Event: Order 1st beer
Think: I am going to forget about himMood: 7Angry: 7Do: Drink
Event: Order 2nd beer
Think: I feel better. Don’t need him!Mood: 5Angry: 5Do: Order another beer
Event: Order 4th beer
Think: I can’t live w/out himMood: 9Angry: 7Do: Go to bathroom; take 100 Tylenol
After Attempt
Identify Links in the Chain for Solutions TARGET VULNERABILITIES: staying up late, no lunch
TARGET
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Dialectical Behavior Therapy Dialectical Behavior Therapy
Skills to ↓ both behaviors4 skill types: To ↑ ability to
Focus on here-and-nowHave + relationshipsRegulate emotionsTolerate – situations/emotions
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This Lecture This Lecture CoveredCovered
DefinitionsDefinitions✔✔
RelationsRelations✔✔
Reasons for drinkingReasons for drinking✔✔
Prevention/TreatmentPrevention/Treatment ✔✔32
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Key Messages Key Messages 40% drink prior to attempt Acute/Chronic use
↑ risk while drinking Reasons
Non-suicide reasons (common) Assessment:
Assess ALL systematically Ongoing assessment of both Explore alcohol-suicide connection
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