Suicidality and Special Populations

10 Suicidality and Special Populations

In this chapter, we examine groups of patients who may require the use of added or special techniques to ensure the best therapeutic outcomes. Included are patients with co-occurring substance abuse or psychosis, children and adolescents, and elders. These populations have additional vulnerabilities in terms of dependence, financial stressors, decreased access to care, and medical or developmental issues influencing their care.

Addictive Behaviors and Suicide: The Patient Who Is Left Out in the Cold

Addictive behaviors, as a class, are strongly associated with increased risk of suicidal behaviors. The term addictive behavior means any behavior pattern whose function is to quickly control or eliminate negative affect, such that the behavior pattern is strengthened and becomes a more dominant emotion control strategy over time. Although there is a panoply of non–substance related addictive behaviors (e.g., bulimia, bulimarexia, anorexia, compulsive gambling, pornography, sexual behaviors), all of which are associated with heightened risk of suicide, in this section we limit our discussion of addictive behaviors to those involving substance abuse, with the caveat that the principles for treating suicidality in patients who abuse substances also will apply to treating those with other forms of addiction.

All health care providers are aware of the enormity of substance-related health problems. Whether you work in a general health care setting, trauma center, or mental health facility, many of your patients have substance abuse or dependency in addition to other conditions. The opioid epidemic in the United States, leading to previously unimagined levels of addiction and unintended, premature death, is an unpleasant reminder of the dark side of illicit drug use and dependence on prescription medication. The area of co-occurring addiction and other mental disorders is of particular concern in psychiatric medicine; individuals suffering from comorbidity are a large part of the treated population, especially in the public setting. The combination of mental disorders and addictive behaviors usually causes severe impairment across multiple domains of life. All areas of functioning can be adversely affected, including family and social interactions, employment, and the ability to meet the basic needs of shelter and food.

Drug and alcohol use disorders vary markedly, ranging from infrequent bouts of alcohol intoxication to the daily use of a number of substances. In many cases, it is not uncommon to find someone who is using marijuana, cocaine, and alcohol daily and who has a number of medical problems in addition to, or because of, substance abuse. Patients with addiction-related disorders are often difficult to treat; a major component of that difficulty can be a lack of motivation for treatment and lack of adherence with treatment recommendations. There is extensive literature on the practical issues involved in rehabilitation and recovery from addiction-related disorders. Several references that we have found helpful appear in the “Selected Readings” at the end of this chapter. Our concern is that this population of patients is fraught with suicidality and far worse health outcomes than the rest of the population. Substance-related disorders have been found to double the risk of suicidal ideation and attempts, and suicide deaths are more common in the context of substance-related addiction (Poorolajal et al. 2016). Suicidal patients with substance use disorders can be difficult to treat and can find themselves caught between agencies, finding no one to address the totality of their problems. A problem-solving approach can work with these individuals, but someone has to be there to administer it.

A major difficulty in providing effective management for the suicidal patient with substance abuse issues is the reluctance of mental health professionals to assume responsibility for care that affects both mental health and chemical dependency treatment systems. A distressingly common scenario plays out as follows: The mental health clinician or the inpatient psychiatric unit refuses to work with the patient because of the continuation of substance abuse. The message is that the patient must get his or her substance abuse cleared up before mental health treatment can proceed. As a result, the substance-abusing patient enters the chemical dependency treatment system in either an inpatient or outpatient program. When the patient experiences suicidality, he or she is immediately discharged from that system with the message that the suicidality needs to be brought under control before chemical dependency treatment can be administered.

Some authorities have suggested that the answer to this dilemma is to create a third service-delivery treatment system for the “dually diagnosed” patient or the patient with co-occurring disorders. This approach obscures the fact that both mental health and chemical dependency counselors are professionally responsible for diagnosing and treating the array of mental health and substance abuse conditions associated with patients who seek care in either system. A mental health counselor needs a strong and sophisticated set of skills in diagnosing and treating substance abuse, and a chemical dependency caregiver needs a good working knowledge of how to deal with suicidal behavior. The fact remains, however, that a large number of patients travel between the two systems and are not receiving comprehensive care for their co-occurring, complex conditions.

Remember that it is your professional responsibility to be concerned with the diagnosis and treatment of conditions that are presented to you for care in any setting. Patients generally do not sort themselves out according to our ideas on how to treat them. The accommodation is our responsibility, not theirs. Practitioners in the chemical dependency, mental health, and general health care systems need to be prepared for the issue of suicidality and concurrent substance abuse.

Principles for Working With the Substance-Abusing Suicidal Patient

The AIM model describes three crucial steps to follow in evaluating and treating a substance-abusing suicidal patient:

A: Ask and ask again about substance use.
I: Integrate substance abuse into the problem-solving context of suicidal behavior.
M: Manage—develop a crisis management plan for handling escalating suicidality due to substance abuse.

It is important to recognize that alcohol and drug abuse share important functional similarities with suicidal behavior; both suicide and substance abuse are ways of controlling or avoiding unpleasant emotional content, and both function as problem-solving behaviors. You can “check out” by trying to kill yourself, or you can do so by getting numbed out from a drug-induced high. Because drugs, alcohol, and suicidality are birds of a feather, there is a direct association between them. This association presents both a challenge and an opportunity in treatment. Left undetected, unintegrated, and unmanaged, substance abuse can unravel the best treatment plan. When detected, integrated, and managed, episodes of substance abuse can be used to further the goals of treatment, much in the way that episodes of suicidality can.

The first step in the AIM model is to learn how to ask about substance abuse and then ask about it again. This diagnostic task can be complex. It is not only a matter of remembering to ask but also a matter of being persistent, getting across the desire to be helpful, and learning not to be defeated by denial. A colleague related the following story, which demonstrates the scope of the problem.

A woman appeared at a university-based affective disorders clinic for treatment of depression and persistent suicidality. Because the facility was a teaching clinic, the woman was interviewed by medical students, residents, and faculty. Using structured interview techniques, each interviewer systematically asked the woman about substance abuse. In every instance, she denied any difficulties. Over the course of a stormy year of treatment, the woman showed little response to medicines or psychotherapy. During this time, she made several suicide attempts. At the end, she failed to keep several appointments, and her relationship with the clinic stopped. Approximately a year and a half after the woman’s last visit, one of the physicians in the clinic came across a newspaper article about the woman. She was being interviewed about her successful recovery from severe cocaine addiction. In the interview, the woman talked about a decade-long addictive disorder and a successful treatment program she had been working on for 6 months. There was no mention in the interview of her yearlong treatment for depression and suicidality.

The lesson from this story is to ask, ask again, and ask in different ways. If physical symptoms, laboratory tests, and reports from family and friends keep your index of suspicion high, keep inquiring. Persistence can sometimes pay off. An undiagnosed and untreated addiction problem will make treatment of any other problem, including suicidality, difficult. It is almost a prescription for treatment failure.

Ask about both the actual use of substances and the effects of substances. Good questions to ask, using alcohol as an example, are these: “How many days during the past month have you had a drink? On those days when you had a drink, how many drinks did you have?” A frequently used acronym for substance abuse is CAGE, which refers to four questions:

C: Cut down—Have you ever tried to cut down on your substance use?
A: Annoyed—Have other people become annoyed with you about your substance use?
G: Guilty—Have you ever felt guilty about your substance use?
E: Eye opener—Have you ever used (this substance) the first thing in the morning to avoid withdrawal symptoms (i.e., as an eye opener)?

A yes to any of these questions can indicate a problem.

The second step is to understand your patient’s substance abuse by integrating it in the context of his or her suicidality. The presence of suicidality suggests that a tandem addictive disorder may be present. People who use suicidality as a means of problem solving often engage in binge eating, binge drinking, and various forms of substance abuse. When you are working with a patient, always try to figure out the role of alcohol, cocaine, marijuana, or anything else being abused in the context of the patient’s suicidality. Does your patient view suicidality as a solution to chronic addiction? Does the patient use drugs or alcohol to escape the emotional pain associated with daily hassles and major stresses? The effects of substance use can be very detrimental when an individual is engaging in value-based problem solving. Just when your patient needs to be thinking most clearly, the use of drugs can adversely affect judgment, concentration, and the ability to think things through and can cause him or her to become more impulsive. This combination can be deadly, as evidenced by the alcohol level recorded in many coroners’ reports for individuals who die by suicide. In addition, when overdose is the method of suicide attempt, many drugs of abuse, especially alcohol, will potentiate the lethal effects of the overdosing medication, making the situation much more deadly.

The third step is to manage substance abuse and suicidality via a coping card (and a crisis management plan) (see Chapter 8, “Managing Suicidal Emergencies”). A common scenario is as follows: The patient is in a problem situation, dealing with an interpersonal difficulty. The patient becomes frustrated and angry. He or she starts to drink to alleviate this emotional pain. The drinking persists, and suddenly, and usually very rapidly, suicide becomes a real solution. At this moment, the patient will often grab a bottle of pills and take them impulsively, often within 30 minutes of a trigger event. Impulsivity is increased by alcohol and so is the potential lethality of the overdose substance. This is a bad situation. The coping card (and plan) needs to address this situation before it arises. Include the following statement on the coping card: “Do not drink, or, if I am drinking, stop drinking.”

Alcohol on Breath in the Clinic

What do you do when your substance-abusing, suicidal patient arrives for treatment intoxicated? Your biggest challenge is to use this event in a way that ultimately benefits the patient and at the same time avoids a destructive, treatment-ending showdown over whether the substance abuse will continue. You must do your best to maintain a relationship with an impaired patient. These moments can be a rare opportunity for accessing something your patient may be very reluctant to talk about: the desperation with which he or she avoids negative feelings. Do not cancel the session or ignore the circumstance. Rather, praise your patient for having the courage to bring such a problematic behavior directly into the treatment. When you use this technique, you are being philosophically consistent with the problem-solving approach to suicidal behavior, namely, that it is permissible to bring your problems into the therapeutic context without unhinging the therapy. The goal in this strategy is certainly not to reinforce substance use. The goal is to get past the impairing effects of drug and alcohol consumption and to understand what your patient is experiencing during this impaired state.

Alcohol disinhibits the expression of emotion and cognition. Although alcohol has a depressant quality, it is likely that much of the feeling and thinking expressed by your patient under the influence has a real and substantial life outside the context of drinking or drugging. It is your task to sort out what expression is impulsive and temporary and what expression is giving you a look at thoughts, feelings, and reactions that are integral to your patient’s worldview. This process requires a rapport between you and your patient, and it requires you to adopt a nonconfrontational stance regarding alcohol and drug consumption. Approximately 50% of all suicide attempts occur in the context of alcohol or drug use, so it is quite likely that proceeding with the session will give you insight into the process by which your patient engages in suicidal behavior. A sound and effective crisis management protocol is easier to produce if you have a comprehensive view of the way that this behavior develops during an episode of alcohol or drug abuse.

Your patient may arrive at the session intoxicated and acutely suicidal. In this case, your task is to help the patient get through impulsive and potentially lethal moments until a clear head prevails. It is generally advisable to keep the patient in a safe setting or to send the patient home with a friend or family member and explicit instructions to remain in the immediate vicinity until the intoxication has cleared. As always, the general philosophy is to use whatever your patient brings to therapy in a way that provides advantage to the patient. In this respect, it is sometimes helpful to call the patient back and conduct a debriefing about whether the episode of alcohol or drug use seemed to work in terms of eliminating or controlling distressing, unwanted mental experiences. The more you can connect dysfunctional problem solving to the experience of lack of workability, the more leverage you will have in getting your patient to consider alternatives.

The Inpatient Substance Abuse Unit

The staff of an inpatient chemical dependency unit deal with problems somewhat differently than the staff in an outpatient treatment setting. The chief task of inpatient treatment is to assist the patient in getting through withdrawal and into early stages of abstinence. Withdrawal can be associated with an increase in suicidality. Withdrawal is often a difficult process, with both formidable and emotionally distressing physical and psychological components. It can create agitation, physical discomfort, and significant mood swings. Because withdrawal symptoms can persist in some people for 2 months or more, it is sometimes difficult to differentiate long-term psychological dysfunction from short-term dysfunction due to substance withdrawal. Most physical effects of addiction and withdrawal improve within 10–14 days, but both sleep difficulties and psychological discomfort can continue for some time and can influence your patient’s behavior.

Dysphoria or symptoms of depression may accompany and complicate continuous substance abuse. In many cases, depression existed before the substance abuse began. Your patient may be dealing with a “double whammy”: organically induced depression due to a stage of drug use (acute or chronic withdrawal, sustained use, or intoxication) combined with a preexisting tendency for depression. Add to this the agitation and physical discomfort often associated with drugs, and the stage is set for potentially lethal suicidal behavior.

Many substance-abusing patients have comorbid psychiatric conditions. These conditions include depression, anxiety, personality disorders, and schizophrenia, all of which are associated with suicidal potential. A psychiatric examination, including assessment of suicidality, should be performed with any patient who is admitted to a substance abuse unit. By all accounts, this population is at high risk of both completed and attempted suicide, and admission for detoxification is a particularly critical phase in management of the disorder. Staff members need to learn how to assess and manage suicidal potential, especially during intensive substance abuse treatment. These processes are conducted with the same techniques used in a psychiatric inpatient setting (see Chapter 9, “Hospitals and Suicidal Behavior”), and there is no reason to believe that the application of these strategies would be any less effective in a substance abuse treatment facility. The task is to provide as much safety and security as possible while avoiding an invasive, nontherapeutic milieu. The unit should adopt policies and procedures that systematize the way in which suicidal behavior assessments are conducted. Appropriate attention should be paid to documenting and treating any psychiatric conditions that may further increase the patient’s suicidality.

A clinically significant difference between many substance-abusing patients and their nonabusing counterparts is the potential for tremendous mood variability that occurs in the first 30 days of treatment following withdrawal. Suicides on detoxification units sometimes occur when the patient is reporting a positive and stabilized mood. Consider the following clinical example.

One of us (K. S.) treated a patient who had both chronic suicidal ideation and a long history of almost daily intoxication. As therapy progressed, the patient’s suicidality diminished, but the drinking behavior escalated and led the patient to accept placement for 30 days in an inpatient treatment program. At first, things seemed to be going quite well. After several days of acute withdrawal symptoms managed by medication, the patient’s sensorium began to clear and his affect improved. He began talking about looking forward to a life free of the daily struggle to stay sober. He reestablished contacts with some family members who had been alienated by his drinking. Two weeks into the treatment, he had become a model patient, attending and participating in various group and individual activities. His affect was stable, and he started to plan for his eventual discharge. On the fifteenth day, the patient ate lunch with everyone, joked around, seemed to be in good spirits, mentioned that he needed to make a phone call to a family member, and excused himself. Fifteen minutes later, he was found hanging by a bedsheet in his room and was pronounced dead at the scene.

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