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Facebook Live: The Intersection of Suicide and Substance Use

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JOSHUA GORDON: Hello and welcome, everyone. Thank you for joining us today. I'm Dr. Joshua Gordon, director of the National Institute of Mental Health, or NIMH for short. NIMH is the lead federal agency for research on mental disorders. Our mission is to transform the understanding and treatment of mental illnesses through basic and clinical research.

NORA VOLKOW: Hello, everyone. I'm Dr. Nora Volkow. I'm the director of the National Institute on Drug Abuse, or NIDA, which is the world's largest funder of research on the health aspects of drug use and addiction. Our mission is to advance science on drug use and addiction and to apply that knowledge to improve individuals and public health.

JOSHUA GORDON: In observance of Suicide Prevention Month, Dr. Volkow and I are joining forces for the next half hour. Each September, people in the United States and around the world help raise awareness and share information about this important public health concern, which is a leading cause of death in the United States and around the globe. At NIMH, I've made suicide prevention one of my top priorities. Our two institutes are, together, taking this opportunity today to highlight and discuss the many intersections of suicide and substance use. Individuals who experience a substance use disorder during their lives may also experience a co-occurring mental disorder and vice versa. Suicide risk is increased among those with either a mental disorder or a substance use disorder or both.

NORA VOLKOW: Indeed. And this intersection emphasizes the need to address substance use disorders and other co-occurring mental health conditions together. So today, we will discuss common risk factors, populations at elevated risks, suicides by drug overdoses, treatment, prevention, and resources for finding help. We'll also take the last five minutes or so to take some of your questions. So please enter them as comments under either NIDA or NIMH's live stream post below and we'll do our best to address them. Please note that we cannot provide specific medical advice or referrals. It is important to consult with a qualified healthcare provider for diagnosis, treatment, and answer to your personal questions. If you need help finding treatment, please visit our sister agency, the Substance Abuse and Mental Health Service Administration or SAMHSA's behavioral health treatment service locator at Findtreatment.samhsa.gov.

JOSHUA GORDON: Because it's Suicide Prevention Month, we also wanted to bring attention to the new 988 Suicide & Crisis Lifeline that launched over this past summer. If you and you know is in crisis, please call or text 988. You can also visit 988lifeline.org for more help and information. The Lifeline provides 24/7 free, confidential support for people in distress. It also provides prevention and crisis resources for you or your loved ones and best practices for professionals across the United States.

All right. With that introduction, let's get into our discussion. As I mentioned earlier, individuals who experience a substance use disorder during their lives may also experience a co-occurring mental illness and vice versa. Co-occurring disorders can include anxiety disorders, depression, attention deficit hyperactivity disorder, or ADHD, bipolar disorder, personality disorder, schizophrenia, among others. And while substance use disorders and other mental disorders commonly co-occur, it doesn't mean that one causes the other. Importantly, people at risk for suicide may struggle with substance use disorders and other concurrent risk factors at the same time.

NORA VOLKOW: Here are some of the other possible links between substance use disorders and suicide. One, drinking or taking drugs can change behavior and mood. Alcohol and drug use may lower a person's inhibitions, worsen depression and feelings of distress, and increase impulsivity, which could turn suicidal thoughts into action. Two, drug use impairs judgment. Drug or alcohol intoxication affects circuits in the brain that help control behaviors. As such, the circuits involving self-inhibition or self-control are weakened in the person suffering from an addiction. This weakening could make a person more likely to think about suicide and act upon it. People who use drugs or alcohol may also feel helpless because of their addiction, which could also make a person much more likely to consider suicide.

Three, chronic pain. Many people start taking prescription opioids to relieve chronic pain. Chronic pain alone, when severe, can lead a person to think about suicide. The pain can also lead to increased opioid use and, potentially, addiction, which, by worsening mood and weakening self-control, further increases the risk for suicide. Unfortunately, the recent reluctance to prescribe opioids due to the overdose crisis can also negatively impact pain patients whose requirement for these drugs is medically justified and who find themselves without the factory treatment alternatives. Fourth, stigma. Someone who has an opioid addiction may feel ashamed. They're also very likely to encounter stigma from family, friends, and society at large, including the healthcare providers. This stigma can increase distress and hopelessness and may raise the risk for suicide.

Recently, a study from NIDA scientists that assess intentional drug overdose, that is, suicides from drug overdoses, found the following: that while overall, there has been a decline in suicide rates by overdoses among men from the period of 2012 to 2019 and among women for the period of 2015 to 2019, that's not the case for other age groups. Specifically, there have been increases in young people aged 15 to 24, increases in older people aged 75 to 84, and increases in non-Hispanic black women. The study also found that women, overall, were consistently more likely than men to die from intentional drug overdoses, with the highest rates observed in women aged 45 to 64.

Nearly 92,000 people died from a drug overdose in the United States in 2020. This represents the largest increase ever recorded in a calendar year and reflects a nearly fivefold increase in the rate of overdose deaths since 1999. For overdose deaths, the proportions of recorded intentional overdose deaths, however, declined from 19% in 1999 to 5% in 2020. However, because it can be difficult to determine whether overdose deaths were intentional or not, the actual numbers and proportions are likely to be much higher. The distinction between accidental and intentional overdose has important clinical implications as we must implement strategies for preventing both. To do so requires that we screen for suicidality among individuals who use opioids or other drugs and that we provide treatment and support for those who need it, both for the substance use disorder and for the other mental illnesses.

JOSHUA GORDON: Screening is so important, but it's also important to be able to know when and where individuals are at risk. Dr. Volkow, I wonder if you might let us know, are there factors such as time of year, length of day, or day of week that can be associated with intentional overdose rates?

NORA VOLKOW: Indeed, and analysis from large databases have shown that intentional overdose rates varied by month of the year, with the lowest rates noted in December and the highest rates in late spring and summer. These findings align with previous observations of seasonal variations in suicide risk. We hypothesize that both social and biological factors contributed to these differences during the year.

For instance, lower rates in December may reflect social interactions and collective optimism during the holiday seasons. On the other hand, the increases in intentional overdose rates with longer daylight hours in May through August could also reflect the increases in the levels of μ opioid receptors in the brain during this period. The μ opioid receptors are the target of opioid drugs, which are the most frequent substances in the identified intentional overdoses. And these changes in the receptor levels could vary the sensitivity to the overdoses from these drugs as well as to their pharmacological effects.

JOSHUA GORDON: So it's really important for clinicians to keep in mind these factors so they can assess patient suicide risk, not just one point in time, but frequently, and as it might change over time. It's also important for friends and family members of people who may be at increased risk of suicide, and, eventually, for those individuals themselves, to know how to look for risk so that they can be aware of the greatest periods of risk, the greatest moments of risk, and seek help when that help is needed. Family and friends are indeed often the first to recognize the warning signs of suicide. And so they can take the first steps towards helping a loved one find mental health treatment.

Warning signs that someone may be at immediate risk for attempting suicide include talking about wanting to die or wanting to kill themselves, talking about feeling empty or hopeless or having no reason to live, talking about terrible emotional or physical pain, talking about being a burden to others, withdrawing from family and friends, giving away possessions, saying goodbye to friends and family, taking risks that could lead to death, such as driving extremely fast, and talking or thinking about death often. Other warning signs are displaying mood swings, particularly extreme mood swings. Suddenly changing from very sad to very calm or happy. Making a plan or looking for ways to kill them themselves, such as searching for lethal methods online, talking about feeling guilt or shame, and alcohol or drug use increasing, acting anxious or agitated, changing in your sleeping habits, showing rage, or talking about seeking revenge.

Now, any one of these factors may not be associated with an increased risk for suicide, but the combination of these factors are enough that if you see that in a loved one or you see it in yourself, reaching out for help is something that you can do. It's important to note also that stressful life events, such as the loss of a loved one, legal troubles, financial difficulties, and other interpersonal stressors, such as feelings of shame, harassment, bullying, discrimination, or relationship troubles, these are things that also contribute to suicide risk, especially when they occur with other suicide risk factors.

NORA VOLKOW: And relapse is another possible red flag. For someone who has been in treatment or in recovery, if they start drinking or using drugs again, they may feel like they failed. And so it is important to recognize that this is not true. For relapse, it's actually normal during the recovery process. And it does not mean that a person is a failure or needs to give up on recovery. Nevertheless, people who relapse may feel very bad about themselves and are at increased risk for suicide as a result.

JOSHUA GORDON: What can one do besides reaching out for help? Well, reducing the suicidal person's access to highly lethal items, that's an important part of a plan for suicide prevention. Well, this is not always easy. Asking if the at-risk person has a plan for how they might attempt suicide and then removing or disabling the means they are considering can make a big difference. Listen carefully. Learn what the individual is thinking and feeling. Research suggests that acknowledging and talking about suicide actually reduces rather than increases suicidal thoughts and suicide risk.

Most importantly, help them get help. Help them connect. Save that 988 Suicide & Crisis Lifeline number in your phone. Call or text 988 so that you have it ready at hand if you need it. You can also help make connections with other trusted individuals, like family members, friends, spiritual advisors, healthcare professionals, or mental health professionals. To get more information about what you can do if you have a friend or a loved one, or if you yourself are contemplating suicide, visit nimh.nih.gov/suicideprevention, one word.

NORA VOLKOW: We know that individuals in substance use disorder treatment often have suicide risk, but unfortunately, it is not addressed or even screened in many instances. We also know there are individuals in psychiatric treatment for suicide risk who do not have their substance use disorder addressed adequately, or even sometimes at all. And this reflects, on the one hand, lack of training, lack of practice standards, as well as stigma. We know that relapse, both for substance use disorder and relapse for suicidal thinking can return and those relapse preventions should be addressed in all interventions.

Changes in treatment, including transitions from hospital to community care, as well as changes in medications, are high-risk periods for substance use overdose or suicide risk. For example, if a patient that has been taking prescribed opioid is tapered off them, it carries both an increased risk for suicide and for overdoses. So what is needed to address both suicide and substance use disorder when we're dealing with treatment? I think, to start with, we should be screening it systematically, and we need to treat the individual holistically. However, there are many challenges to overcome.

It is not routine practice in our healthcare system to integrate treatment for substance use disorders, psychiatric conditions, and suicide risk. These are most frequently compartmentalized than integrated. A current problem among individuals with substance use disorders is also treatment avoidance because of the fear of losing their jobs if an employer finds out that they have a substance use disorder or fear of losing custody of their children.

JOSHUA GORDON: These challenges beg for research solutions and, fortunately, we're making progress. New intervention approaches that seek the least restrictive approaches, that involve shared patient-provider decision-making, they're being tested now and providing promising results. For example, a recent study by the Veterans Administration found that buprenorphine treatment for opioid use disorder reduced the risk of suicide as well as overdose deaths. Coupling medication treatment with psychosocial interventions can be really important.

One promising intervention is called preventing addiction-related suicide, or PARS. It's a suicide prevention module developed in and for community substance use intensive outpatient programs. This module was found superior to usual care in improving suicide knowledge, maladaptive attitudes, and enhancing help-seeking in adults undergoing addiction treatment in the community. It's a one-session intensive outpatient program module that was developed in partnership with these community-based agencies. PARS has the potential for wide impact in the national suicide prevention strategy.

Other efforts are focused on enhancing the care of individuals with co-occurring mental illnesses and substance use in primary care settings. The Helping to End Addiction Long-Term Initiative, also known as HEAL, is an NIH-wide initiative that is studying a range of different approaches to reduce and reverse the opioid overdose epidemic. The HEAL Initiative is supporting clinical trials that develop, optimize, and test collaborative care models in primary care to help people with opioid use disorders, co-occurring mental health conditions, and suicidality. In these collaborative care models, medications can be offered alongside psychosocial interventions and other treatments for both the mental health condition and the opioid use disorder and are a promising means to reduce suicide.

The best approach to prevent substance use and suicide risk is to avoid-- the best approaches are needed to prevent both substance use and suicide risk to avoid years, and possibly lifetimes, of significant human suffering. We have substantial evidence that substance use can be delayed or prevented and that these programs are highly cost-effective. Because of the overlap in risk and protective factors, many of these programs also appear to reduce the likelihood of suicide thoughts and behaviors. We need continued research in this area to be able to ensure that the treatments of tomorrow are even better and then extend their reach.

One important area of future research is in teenagers. Numerous NIH-supported studies, such as the Adolescent Brain and Cognitive Development Study, or ABCD, have shown that preteens have suicide risks and that those risks are elevated for those with substance use and that the risk factors overlap in teens as well as in adults. These data point to the need for treatment researchers to continue to include measures of substance use, psychiatric symptoms, suicidal thoughts and behaviors in our research studies so that we learn how interventions work across these related problems.

NORA VOLKOW: We have now reached the end of our important discussion today. Thank you all for tuning in and for your participation.

JOSHUA GORDON: I think we're going to take some questions first, Dr. Volkow.

NORA VOLKOW: Oh, they're ready already?

JOSHUA GORDON: You jumped the gun a little bit.

NORA VOLKOW: I was saying that we wanted to get questions. Absolutely.

JOSHUA GORDON: I think I can ask the first one, but I think maybe it's good if you were to answer it.

NORA VOLKOW: Yes, you can go. Yes.

JOSHUA GORDON: Question number one from our-- question number one from our audience. Can you please address post-acute withdrawal syndrome, also known as PAWS, and how this might be related to suicide and, in particular, how we can encourage more people to be aware of this syndrome in clinical settings?

NORA VOLKOW: A very important question. And indeed, the post-acute withdrawal syndrome actually is one that can vary from short duration to very, very long duration and is characterized frequently with negative emotional states such as depression, anxiety, inability to sleep properly, irritability. And it's a period that, if not addressed properly and supportive, can, on the one hand, result in increased risk for relapse and drug-taking. Actually is one of the factors that leads to drug-taking, but it also raises the risk of suicide, in part to try to actually obviate the suffering from the withdrawal. And as the person that asked the question noted, unfortunately, this is not recognized by many clinicians, even some that are involved with patients with substance use disorders. They have the sense that if you are someone that has not had alcohol for one month, that withdrawal should not be there, when in fact, we see persistence in many individuals months after last use of taking the drug. So this needs to be addressed. And there are supportive interventions, evidence-based, that can improve the outcomes and the well-being of individuals during this phase of their drug discontinuation.

JOSHUA GORDON: Another question that I hope I can answer, and Dr. Volkow, you can fill me in later if I miss something, is how would you recommend the providers incorporate treatment for substance use disorders and suicide risk in their practices? There's a few steps that providers can take, even if they're not yet fully experienced in treating patients. The first thing that you have to do, and every provider needs to do this, is ask about both. It's important that in all your patients, you ask about substance use, you screen for the potential for substance misuse or substance use disorders, and you screen for suicide risk. You ask people, "Have you been thinking about death? Have you thought about harming yourself or killing yourself?" Those simple questions can alert providers as to the risks for their patients.

Now, to incorporate treatment practices, it's important that providers who don't know the latest evidence-based practices-- that they get help. Collaborative care models integrate mental health professionals in a consultatory way to help providers know how best to treat their patients. So providers can enter into those relationships. And also, they can refer to mental health professionals where those professionals are available in those communities. For more information, I encourage you to visit both the NIDA websites and the NIMH websites, which can provide additional details. There's another question here--

NORA VOLKOW: Yeah. And I think that--

JOSHUA GORDON: Yeah. Go ahead. Go ahead, Doctor.

NORA VOLKOW: Yeah. No, I was just going to comment-- that's an excellent response, and I just wanted to highlight that one of the advantages that we currently have to create and facilitate this integrative approach is the access to telehealth because that can immediately put you in contact with an expert and can also put you in contact, for example, with peer navigators. So, currently, we have the optimal technology to facilitate a clinician that doesn't have sufficient experience or when they are dealing with someone that has a higher severity that requires more specialized care to get access to it.

JOSHUA GORDON: That's a great point. The next question, I think, Dr. Volkow, perhaps you'll take a stab at first. How can we reduce the stigma surrounding treating people who are at risk for suicide and substance use disorders?

NORA VOLKOW: Yeah. No, I think that the first thing that we need to do is speak about it. And I guess that's what we are actually speaking right now at this moment. And basically, this is a question that hits me because my grandfather actually committed suicide when he relapsed from alcoholism. So I'm very, very sensitive to this issue. And I also realized that because of the stigma, they don't reach out for help. And the family themselves actually, many times, keeps this as a secret as opposed to bringing it up in the discussion. You mentioned before something that I think is worthwhile to repeat, and that is the notion of asking about suicide does not increase the risk of suicide. In fact, it gives an opportunity for the person to seek help. And the same thing is true for substance use disorder. Asking someone about their substance use does not in any way encourage them to use it. It opens a door for the possibility of dialogue and for their ability to reach out and get help.

JOSHUA GORDON: Thanks for that, Dr. Volkow. Great answer. And the next question, which I'll try to take a stab at, what are some of the barriers to accessing services for suicide risk and substance use disorders? We have to acknowledge there are multiple barriers. Obviously, stigma is one of them. If you're ashamed or worried about the consequences of seeking help for treatment, that can be a true barrier. We have to also acknowledge that treatment providers should encourage you to reach out to the number, use the SAMHSA website to help find service providers. If you have health insurance, use your health insurance to help find service providers because that's the first step. And that is a significant [inaudible]. You can also reach out to your primary healthcare provider to get help with referrals.

Then we have to acknowledge, finally, that a barrier to accessing treatment is that the treatments can be challenging. There [inaudible] require engagement. They require work on the part of the individual [inaudible] to make it easier. But there are treatments available that work. And so we want to try to make sure that we can expand access to those efficacious treatments as much as possible.

NORA VOLKOW: And if I can jump in, I just want to--

JOSHUA GORDON: I think now we're-- [inaudible].

NORA VOLKOW: Yeah. No, sorry. I was just wanting to emphasize a point that I think is very important to all of the things that you have stated. Another challenge is that we need to realize that both of these conditions are chronic conditions. And it's not like an infection that you take an antibiotic and you're cured. And so you need continuity of care. So Dr. Gordon was saying you need to work on it, but you also need to keep at it. And that element of considering these conditions as chronic conditions is crucial to increase the likelihood of an individual achieving recovery and to be able for that person to overcome the suicidal urges or thoughts.

JOSHUA GORDON: Well, thank you, Dr. Volkow. We've reached the end of our important discussion today. Thank you all for tuning in, for your participation, for the wonderful questions. We want to remind you again that if you need help finding treatment, there's a lot of options to help. Please, for example, visit SAMHSA's behavioral health treatment services locator at Findtreatment.samhsa.gov. And if you or someone you know is in crisis, please call or text the 988 Suicide & Crisis Lifeline at 988. You can also visit 988lifeline.org for more help and information. Thank you and stay well.

NORA VOLKOW: Thanks.