Q&A with Dr Nicole Lee: Suicide co-occurring with alcohol and other drug use

There is a clear but very complex relationship between alcohol and other drug use, mental health and suicide risk.

Ongoing heavy alcohol use and alcohol intoxication increase the risk of suicide. Intoxication increases the likelihood of moving from thinking about suicide to acting on suicidal thoughts and increases the risk of death as a result of suicide.

On the flip side, people with mental health conditions are disproportionately represented among those who die by suicide, with substance use disorders being a contributing factor in many cases.

Alcohol and other drug use can impact decision-making and make it more difficult for people to regulate their emotions and manage impulsivity, contributing to the increased risk of self-harm or suicidal thinking.

Certain mental health conditions do seem to co-occur with alcohol and other drug use issues at a higher rate. Primarily alcohol, but also other drugs, can both drive and increase the risk of these mental health disorders.

One of the most common is anxiety (especially social anxiety, generalised anxiety and panic disorder). The prevalence of alcohol and other drug disorders among people with anxiety disorders is estimated to be up to 40%.

Mood disorders, like major depression, also commonly co-occur; the estimated lifetime prevalence is up to 40%. Post-traumatic stress disorder (up to 60%) and other substance use disorders (around 40%) also commonly co-occur with alcohol and other drug disorders.

Women are less likely to seek help for alcohol and other drug issues than men, and when women do seek help, they tend to have much more severe symptoms and commonly experience mental health issues. Fear of stigma, especially in relation to parenting, is one likely driver for delayed help seeking. Women also have a range of unique barriers preventing them from entering treatment including primary responsibilities caring for children and a severe shortage of women-only services. Women are more likely to have post-traumatic stress disorder, commonly as a result of family violence, and tend to do better in women-only services.

Men are less likely to access mental health services than women possibly for similar reasons: Stigma, especially driven by traditional gender roles such as fear of seeming “weak”.

There isn’t a lot of good data specifically about gender differences in seeking help among people with co-occurring conditions but given the high co-occurrence the same issues are probably barriers for men and women.

Once in treatment, women and men do equally well, so addressing these gender-specific barriers is really important to improving earlier intervention and access to support.

Other high-risk groups that need tailored support are people who identify as lesbian, gay, bisexual, transgender or intersex (especially youth), Aboriginal and Torres Strait Islander people (especially youth), and people who are incarcerated.

Traditional active screening for suicidal thinking or behaviour is no more effective than screening only for depression.

This makes good screening for mental health symptoms very important for alcohol and other drug services, as well as primary care. Conversely, given the interplay between alcohol and other drug use, mental health and suicide, mental health practitioners should regularly assess for alcohol and other drug use.

A collaborative, non-judgmental approach, which can be facilitated by using a motivational interviewing style is recommended to identify alcohol and drug misuse and/or suicidal thoughts and behaviours.

The presence of both conditions creates a complex clinical challenge that requires a coordinated approach. Most suicide prevention interventions don’t include alcohol or other drug use, and there is relatively little robust evaluation of programs.

Concurrent integrated treatment for co-occurring issues is effective, but for some people sequential and parallel treatment is just as helpful. Although integrated treatment is often a public health goal there is not a lot of evidence to support it. Often, reducing alcohol or other drug use can reduce mental health symptoms without further intervention.

Therapeutic interventions with demonstrated effectiveness in preventing suicidal distress among those with co-occurring disorders are the same interventions effective in both alcohol and other drug treatment and mental health treatment - including cognitive behaviour therapy, dialectical behaviour therapy, and motivational interviewing. Antidepressant medication seems to help reduce suicidal attempts. Peer support programs and harm reduction programs also play a role in engagement and sustained recovery.

Policy interventions can also help, including reducing the free availability and advertising of alcohol, especially initiatives that reduce intoxication, and reduce access to lethal means of suicide.

Most important is a detailed tailored assessment and treatment plan that addresses the person’s unique needs, which may include any combination of effective interventions and modes of delivery.

There’s certainly a role for specialist services that are designed to address both alcohol and other drug and mental health disorders but given the high rate of co-occurrence they could only feasibly respond to people with the most urgent and severe symptoms.

Integrating alcohol and other drug and mental health systems has not been a successful approach in the past. There are significant funding and workforce disparities between these services and not everyone who attends these services has a co-occurring issue.

Alcohol and drug services, for example, receive only one tenth of the funding of the mental health sector. Also, alcohol and other drug services have a much broader brief than the clinical focus of mental health services, including early intervention and harm reduction.

But we do need some way to ensure that all the needs of people presenting to either service are addressed. Coordinated care is essential. This means ensuring that the workforce in the alcohol and other drug sector needs to be able to identify and support people with mental health problems, and vice versa, and clear referral pathways.

Peer support and the involvement of people with lived and living experience in a meaningful way would increase options for support, especially before and after tertiary treatment.

When GPs recognise, assess and treat depression it also helps to prevent suicide, and GPs who assess alcohol and other drug use can significantly reduce use and further reduce suicide risk. Ensuring that there is support for GPs to undertake opportunistic screening for mental health issues, especially depression, and at least alcohol use can assist in reducing risk.

Educating young people about depression, suicide and alcohol and other drug use seems to be effective in reducing suicide behaviour, so education in schools and other places young people access is important.