Alcohol Use and Suicidal Behavior in College Students

Alcohol Use and Suicidal Behavior in College Students Dorian A. Lamis, Ph. D Department of Psychiatry & Behavioral Sciences Emory University School of Medicine

Alcohol, Suicide in Students • Alcohol use – ~75% alcohol use past year – ~40% drink > 4 -5 drinks/occasion past month – 20% have alcohol-related Dx • Suicidal behavior (SB) – 2 nd leading cause of death – 18% ever seriously considered suicide – 8% lifetime suicide attempt © Alcohol Medical Scholars Program 2

Clinical Case – Jane (Initial Visit) • Check-up visit with personal physician • 19 yr. old female • 3 -4 drinks/3 X week • No suicidal ideation • Some depressive symptoms • Behind with schoolwork • Missing classes weekly • Interpersonal difficulties © Alcohol Medical Scholars Program 3

Lecture Covers • Definitions • Alcohol use and SB relationship • Clinical implications • Prevention implications • Treatment approaches © Alcohol Medical Scholars Program 4

Lecture Covers • Definitions • Alcohol use and SB relationship • Clinical implications • Prevention implications • Treatment approaches © Alcohol Medical Scholars Program 5

Definition of Alcohol Use • Standard drink = 10 -12 g pure ethanol – Beer: 12 oz/355 ml – Wine: 4 oz/120 ml – Spirits: 1. 5 oz/44 ml • Heavy episodic (HED) – Blood Alcohol Level (BAC) – HED ≈ 0. 08 BAC – 4/5 drinks ♀/♂ within 2 hr © Alcohol Medical Scholars Program 6

Alcohol Use Disorder (AUD) – ↑ Amount/time spent drinking – Desire/inability to ↓/stop – ↑ Time obtain/use/recover – Craving – Failure to fulfill life obligations – Hazardous use – Giving up important activities – Tolerance – Drinking despite social problems – Withdrawal – Drinking despite health problems © Alcohol Medical Scholars Program 7

Definition of Suicidal Behavior • Suicidal ideation (SI) – Thoughts of killing oneself • Suicide attempt – Non-fatal outcome with intent to die • Suicide death – Fatal outcome © Alcohol Medical Scholars Program 8

Lecture Covers • Definitions • Alcohol use and SB relationship • Clinical implications • Prevention implications • Treatment approaches © Alcohol Medical Scholars Program 9

Alcohol Use and Suicidal Behavior • AUDs and: – Suicidal ideation: ↑ 4 X vs. no AUD – Suicide attempts: ↑ 6 X vs. no AUD – Suicide deaths: ↑ 9 X vs. Gen. Pop • HED (4+♀/5+♂) and: – Suicidal ideation: ↑ 2 X HED vs. no HED – Suicide attempts: 17% HED vs. 7% no HED – Suicide deaths: ~20% decedents ≥ 0. 08 BAC © Alcohol Medical Scholars Program 10

Potential Pathway 1: Alcohol Use & SB • Alcohol use → impulsive/aggressive behaviors • Impulsive/aggressive behaviors → life strains – Negative life events – Interpersonal difficulties – Alcohol-related problems • Life strains → depressive symptoms • Depressive symptoms → SB Lamis & Malone, 2012 © Alcohol Medical Scholars Program 11

Potential Pathway 2: Alcohol Use & SB • Depression → hopelessness • Hopelessness → lack of connections/purpose in life • Lack of connections/purpose in life → alcohol use • Alcohol use → SB Lamis et al. , 2016 © Alcohol Medical Scholars Program 12

Both Likely To Operate • Major depressions confer risk for SB • Co-morbid alc use and/or AUD → additional risk • Many other variables involved © Alcohol Medical Scholars Program 13

Lecture Covers • Definitions • Alcohol use and SB relationship • Clinical implications • Prevention implications • Treatment approaches © Alcohol Medical Scholars Program 14

Clinical Implications • Screening - 85% depressed/suicidal students not receiving help • Variety of settings - Throughout the school - Students coming for emergency care - College counseling centers - Primary care providers - Fraternities/sororities - Within athletic programs © Alcohol Medical Scholars Program 15

Screening Tool for Alcohol Use Disorders Identification Test (AUDIT-C) • Items on: - Frequency of any alcohol use - Typical number of drinks - Frequency of 6+ drinks • Responses are summed • Score > 3/5 ♀/♂ indicates at-risk drinking © Alcohol Medical Scholars Program 16

Screening Tool for Suicide Risk Beck Scale for Suicide Ideation (BSSI; 19 items) • 5 screening items, 14 items intensity of ideation • Responses are summed • Score of >2 on 5 -item screener = high risk • ↑ score on total scale = ↑ suicidal ideation © Alcohol Medical Scholars Program 17

Lecture Covers • Definitions • Alcohol use and SB relationship • Clinical implications • Prevention implications • Treatment approaches © Alcohol Medical Scholars Program 18

Prevention Implications-1 • Docs should know about suicide risk factors - ~45% suicides met w/ physician - ~20% met with mental health provider • Docs: Alcohol OR suicide risk present - evaluate both - Screening: If one risk present, screen for other - Monitoring: How both change over time - Prevention: If neithere, how to prevent - Treatment: How to reduce/stop both behaviors © Alcohol Medical Scholars Program 19

Prevention Implications-2 • Ask about SB - Asking does not ↑ SI - High-risk pts: asking can ↓ SI/distress • If SI is present, ask: - Frequency, intensity, duration - Plan/preparatory steps - Intent © Alcohol Medical Scholars Program 20

Prevention Implications-3 • Is EMERGENCY if: - Recent social stressors and/or loss of resources - Severe psychiatric symptoms - Hopeless - Has suicide plan - Has available lethal means to carry out plan • If emergency must take to mental health worker or ED © Alcohol Medical Scholars Program 21

Initial PCP Evaluation: Jane Revisited • No SI (Beck suicide scale = 0) • Drinks 3 times/week; 4 drinks/occas (AUDIT-C = 4) • No evidence of AUD • Mentions relationship problems • Reports depressive symptoms © Alcohol Medical Scholars Program 22

Jane: Follow-Up Visit • Drinks ↑ and more often (AUDIT-C = 7) • Failing two classes • Boyfriend broke up with her • Hopeless • SI (Beck suicide screen = 3; total = 16) © Alcohol Medical Scholars Program 23

Lecture Covers • Definitions • Alcohol use and SB relationship • Clinical implications • Prevention implications • Treatment approaches © Alcohol Medical Scholars Program 24

Motivational Interviewing (MI) • Therapeutic relationship collaborative • Focused on pts thoughts/feelings • Practitioner guides talk • Motivate pt to change unhealthy behaviors • Build motivation and commitment to live • Explore ambivalence about change • Guide pt towards change © Alcohol Medical Scholars Program 25

CBT for Suicide Prevention-1 Initial phase (weekly sessions 1 -3) • Education - Nature of SB - How alcohol ↑ depression/SI - Restricting lethal means • Behavior chain analysis - Individual in environment - Step-by-step sequence of events→ SI © Alcohol Medical Scholars Program 26

CBT for Suicide Prevention-2 • Collaborative safety planning - Coping strategies - List sources of support if SI • Reasons for living - Identify reasons for staying alive - Hope kit: Photos/trinkets © Alcohol Medical Scholars Program 27

CBT for Suicide Prevention-3 Middle phase (weekly sessions 4 -9) • Skills modules - Behavioral activation – ↑ pleasurable activities - Mood monitoring – Track daily moods - Emotion regulation 1) Do something enjoyable 2) Become anxious by worrying © Alcohol Medical Scholars Program 28

CBT for Suicide Prevention-4 • Skills modules (cont. ) - Cognitive restructuring 1) Identify irrational thoughts 2) Provide alternate thoughts - Assertiveness skills 1) Effectively express point of view 2) While respecting others’ rights/beliefs © Alcohol Medical Scholars Program 29

CBT for Suicide Prevention-5 End phase (weekly sessions 10 -12) • Relapse prevention - Review of suicidal crisis & high risk scenarios - Debriefing and follow-up • Continuation phase (6 biweekly sessions) - Review skills - Discuss reactions to treatment & termination © Alcohol Medical Scholars Program 30

Integrated CBT for ALC & SB - 1 • Guided by social cognitive learning theory (SCLT) - SCLT: Learning of social behaviors and core beliefs → MH problems - Assessment of alcohol use and SB - MI to improve motivation and readiness to tx - Develop self confidence/esteem © Alcohol Medical Scholars Program 31

Integrated CBT for ALC & SB - 2 - Decrease underlying maladaptive cog/beh - Improve communication skills - Enhance problem solving - Improve emotion regulation © Alcohol Medical Scholars Program 32

Dialectical Behavior Therapy Skills to ↓ alcohol and SB • 4 types of skills: ↑ ability to - Focus on here-and-now - Have positive interpersonal relations - Regulate emotions - Tolerate bad situations/negative emotions © Alcohol Medical Scholars Program 33

Conclusions/Summary • Alcohol use and SB co-occur • ↑ Systematic screening needed • Ongoing assessment of both behaviors • Identify/address alcohol use – suicide risk link • Address both behaviors = most effective © Alcohol Medical Scholars Program 34