Author: John Carter

Drinking and suicide: How alcohol use increases risks, and what can be done about it

Young people are particularly susceptible to alcohol-related harm [20] and accordingly, youth suicides seem particularly amenable to alcohol policy changes such as drink-driving countermeasures and increasing the MLDA. Safety planning is a brief intervention to help individuals survive suicidal crises by having them develop a set of steps to reduce the likelihood of engaging in suicidal behavior. Safety planning is frequently included as an element in cognitive behavioral interventions for suicide prevention and can also be used as a brief standalone intervention, typically paired with a referral for mental health treatment. Reduced serotonergic functioning, implicated in the pathophysiology of depression and suicidality [62, 63], may also play a role in OUD [231]. Serotonin availability at postsynaptic 5-HT1 A receptors modulates pain levels by inhibiting firing of sensory neurons.

We can develop a warped perception of suicide, weakening our efforts to avoid pain and protect our well-being.

Shared Neurobiological Features of Suicide and Alcohol Use

Cognitive behavioral therapy (CBT) for co-occurring mood and AUD focuses on dysfunctional, distorted, or self-defeating schemas or beliefs that may be contributing, jointly or severally, to depressed mood, suicidality, and alcohol misuse [133]. MI and CBT interventions have shown the greatest success among psychotherapeutic interventions used in populations with co-occurring alcohol misuse and depression and/or anxiety, even in brief interventions [134], and longer-term treatments produce still better outcomes. In combination, MET/CBT interventions have shown effectiveness in adolescent populations with co-occurring MDD and AUD [135]. Other interventions, such as relapse prevention therapy (RPT) and contingency management (CM), directly target the psychological reinforcement mechanisms that maintain addictive behavior. While they have been effective in populations with AUD/SUDs, there is limited evidence of their utility in co-occurring suicidality/depression and alcohol misuse [136].

This includes protecting against biological, behavioral, environmental, and cultural factors. Effective clinical care for patients with alcohol use disorder as well as other psychiatric and medical disorders will mitigate suicide risk, given the preponderance of evidence linking alcohol use disorder and suicidal behavior. In addition, easy access to a variety of clinical and nonpharmacological interventions can be helpful. These interventions may include psychotherapy, motivational interviewing, cultural and family engagement, fostering spiritual beliefs, and limiting access to alcohol at the community level. Additionally, clinicians should address coexisting smoking addiction, because people with psychiatric disorders often have a truncated life span due to smoking related diseases and premature mortality, compared with the general population.

Alcohol and suicide

For example, in a study of adolescents with AUD receiving fluoxetine for depression, those who also received a manualized CBT/MET protocol had superior outcomes for depression and alcohol-related symptoms compared to those who did not [135]. However, extant data are not conclusive [115•], and further research is necessary to evaluate the combined effectiveness of psychotherapy and pharmacology in co-occurring suicidality and AUD [138]. The studies included in the review predominantly investigated the effect of restrictions on alcohol availability and increased cost of alcohol, and majority found associations with reduced suicides across Western and Eastern Europe, as well as the US. Public policies should be looking to increase awareness of the link between alcohol and suicide and to assess and treat problematic alcohol use as a way to prevent suicide.

1. Additional meta-analytic research similarly suggests lower performance of SSRIs relative to tricyclics in comorbid MDD and AUD/SUD [119, 125], but results should be interpreted cautiously given the potentially mediating roles of study design and sample selection.
2. The goal of intervention is to treat acute, modifiable risk factors and to continuously ensure the patient’s safety (19).
3. There is also a lack of systematic reviews on the impact of alcohol restrictions on suicidal behavior at the individual and aggregated levels.
4. Because patients with substance use disorders are prone to suicidal ideation and attempts, clinicians need to screen such patients for suicidal thoughts and behaviors routinely and continuously throughout treatment.
5. A meaningful understanding of the different roles that alcohol and opioid use can play in suicidal behavior, however, will require continued study of their shared risk factors, mechanisms, and interventions.

The results of our research highlight just how needed these measures are in our society, but prevention requires change at both the individual and systemic level. There are well-established links between alcohol and cancer, heart disease and violence. However, more investigation is required before making any statements on the link between alcohol and suicide. Part of preventing suicide is raising awareness around the topic and bringing it into conversations. The topic of suicide is surrounded by secrecy, which is one of the barriers to getting treatment for people who need it.

A Closer Look at Substance Use and Suicide

As yet, however, there are no FDA-approved medications specifically indicated for suicidal ideation, urges, or behavior [113]. A few pharmacotherapies have been approved for the treatment of alcohol misuse [114, 115]. They include disulfiram, which produces aversive symptoms following alcohol intake; acamprosate, thought to mitigate withdrawal-related symptoms; and naltrexone, a nonselective opiate receptor antagonist that reduces alcohol cravings.

Following de-duplication, 6519 individual records remained, with 6397 records being excluded after title and abstract screening. The remaining 122 full-text records were assessed for eligibility with 19 papers remaining in the final review (Figure 1). They may think they’re a burden to others and begin to develop a higher pain tolerance and fear of suicide. People with problematic alcohol use are also a vulnerable population and we owe them a special duty of care; that should also inform public policies. If it means saving a loved one, warning labels on beer cans seem like a pretty low price to pay.

4. Mixed Policies

Although the methods and effect sizes varied substantially in the studies, reducing alcohol often led to reduction in suicidal behavior. Ecological-level studies predominantly investigated the effect of restrictions on alcohol availability and increased cost of alcohol, and the majority presented a reduction in suicides across Western and Eastern Europe, as well as the US. The majority of studies were rated as unclear risk of bias for a number of domains due to a lack of clear reporting. Policies targeting harmful alcohol consumption may contribute towards a reduction in suicidal behavior at the population level. Alcohol use, both abuse and acute consumption, has been found to be an important contributing factor for suicidal behavior at the individual level [1,2,3,4]. A number of potential mechanisms have been proposed, including increases in impulsivity, aggression, depressive and suicidal thoughts, and feelings of hopelessness, especially if people are predisposed or have depression.

Opioid drugs enhance this effect by overriding GABA-mediated inhibitory control of serotonergic neurons, causing increased serotonin release that contributes to the drug’s analgesic effects. Additionally, activation of 5-HT1 A receptors modulates dopamine transmission, thereby inhibiting the reinforcing or euphoric effects of opioids [232]. Over time, opioid abuse may lead to adaptive changes in the brain that impair serotonergic modulation of pain and reward, resulting in increased pain sensitivity and opioid dependence [231, 233]. Because patients with substance use disorders are prone to suicidal ideation and attempts, clinicians need to screen such patients for suicidal thoughts and behaviors routinely and continuously throughout treatment. Collaboration between substance use treatment providers, other health care practitioners, family members, and community resources is imperative to the successful rehabilitation of patients with substance use disorders. Another strong correlation is that alcohol and mind-altering substances are used as means of self-medication to cope with untreated mental health disorders, the symptoms of which are reciprocally exacerbated by substances.

Furthermore, nicotine use has been shown to contribute to deaths by suicide (18, 22). Patients who are reluctant to adopt pharmacological recommendations should be referred for nonpharmacological treatment modalities as described above. Alcohol consumption has been found to be related to suicidal behavior at the individual and population level, but there is lack of literature reviews on the effect of alcohol policies on suicidal behavior. Therefore, the aim of the current study is to conduct a systematic literature review of the impact of alcohol policies at the population level on suicidal behavior and ideation. We searched the Cochrane CENTRAL, Cochrane DARE, EMBASE, Medline, ProQuest, PsycINFO, PubMed, SCOPUS, and Web of Science electronic databases in March 2019. Papers analyzing alcohol policies limiting alcohol use and studying suicidal behaviors as an outcome measure were included; we identified 19 papers.

As Canadians weigh the pros and cons of adopting the new drinking guidelines, they should be thinking not just about the risks to their physical health, but also to their mental health. A US study examining the MLDA on suicide rates compared states with a younger MLDA of 18 years to those with an older age requirement of 20–21 years [23]. The study compared youth suicide across the 48 states (1970–1990); states with younger MLDAs had 8% higher suicide rates amongst 18- to 20-year olds and 6% higher rates in 21- to 23-year olds, even following adjustment for a number of indicators of socioeconomic disparity [23]. When struggling with suicidal thoughts and tendencies, it’s common to want to escape the pain you’re feeling inside. This is why many individuals often turn to risky behaviours, including using drugs and alcohol. Women could be at greater risk because heavy drinking generally has more negative physical and cognitive consequences for women than men.

While the prevalence and destructiveness of suicide is clear, much less is known about why people die by suicide. This strategy provides for participation in activities that exclude alcohol, tobacco, and other drug use. Constructive and healthy activities offset the attraction to, or otherwise meet the needs usually filled by, alcohol, tobacco, and other drug use, which ultimately reduces suicidal tendencies.

Purpose of Review

Childhood trauma (e.g., physical or sexual abuse) is a particularly significant early risk factor for suicide [159] and is highly prevalent in OUD [160–162]. Indeed, a history of childhood abuse significantly increase the risk for suicidal behavior in individuals OUD [144, 149, 157]. Taking a closer look at family engagement as an intervention in substance use disorders, the clinician should engage the patient’s family and friends in forming a crisis plan. For example, a crisis plan for a person who abuses opioids should include education and naloxone, particularly for those with a high risk of reattempting suicide via opioid overdose.

Patients at high risk for suicide should be hospitalized as a precaution, and detoxification treatment should be started immediately. Subsequently, it is crucial to make the patient aware of the process of rehabilitation. In the case of opioid use disorder, this can involve methadone and buprenorphine treatments, which have been shown to protect against suicide. Methadone treatment in particular has been shown to make patients 20% less likely to commit suicide (21). When treating patients with alcohol use disorder, a multilevel model of protection is recommended.