Australasian Psychiatry • Vol 7, No 1 • February 1999 • 23

Dr Peter TuckerClinical DirectorAdult Treatment ProgrammesWestmead HospitalWestmead, NSW 2145Tel: (61 2) 9845 6817Fax: (61 2) 9635 7734Email:petert@neuro.wh.su.edu.au

The connection between substanceabuse and self-harm has been well

recognized in the literature for sometime, and may even be the basis forrising youth suicide rates [1]. However,this knowledge is not always reflectedin clinical practice. When psychiatricassessments are made of suicideattempters the contribution ofsubstance abuse is often passed overquite lightly. Of even greater concern isthe general lack of skills and focus onmanagement of self-harm in specializeddrug and alcohol services, despite theirhigh-risk clientele. Furthermore, theseservices often experience difficulty inaccessing psychiatric support.

BACKGROUNDWith the possible exception of tobacco, alcohol isthe major harmful substance of abuse in Australia.We know that the lifetime risk for suicide inalcohol dependence is 7%, higher than forschizophrenia or affective disorder [2]. Whenalcoholics attempt suicide, they tend to use morelethal methods for a given level of intent [3]. Lessis known about abuse of other substances, onereason being the difficulty in distinguishingbetween accidental and deliberate opioidoverdoses; however available estimates indicatethat suicide rates are substantial [4]. Additionally,fatal drug overdoses tend to occur in the context ofpolydrug abuse, which includes alcohol [5].Severity of suicidal ideation in substance abusersis associated with higher rates of substance abuse[6] and the presence of other psychiatriccomorbidity [7].

One likely connection between substanceabuse and suicidality is through their relationshipwith depression. Some 40% of alcoholics haveepisodes of major depression; in two-thirds ofthese cases the depression appears to besecondary to the alcohol abuse, and will not bepresent otherwise [8]. One active alcoholic intwenty admitted with depression is likely to die bysuicide within two years without remission fromalcoholism [9]. These findings suggest thatdepression when combined with alcoholism is anespecially powerful indicator of suicidality, andthat an important way to reduce this suicidalitymay be to achieve remission of alcoholic drinking.

SUBSTANCE ABUSE AND SUICIDALITY

PETER TUCKER

A second likely mechanism is via thedisinhibiting effect of many substances, especiallyalcohol, allowing the breakthrough of self-destructive impulses into behaviour duringintoxication. This appears to be even moreimportant than habitual substance abuse [10]. Notuncommonly the person in emotional crisis willresort to substance abuse as a coping strategy, butof course if there is self-harm ideation this may bedisastrous. Sometimes these persons are wellaware that their risk of implementing self-harmingbehaviour will increase with intoxication, andseem to use the intoxicant to facilitate thisfrightening action. Others appear to have had nosuch conscious intentions. Such individuals maynot be habitual substance abusers, and so do nothave the obvious ‘suicide risk factor’ of substanceabuse.

RELEVANCE TO HEALTH POLICYThese basic notions can be readily applied topublic policy on suicide prevention.

The first matter to note is the existence of alarge, identified, readily accessible at-riskpopulation who are at present receiving very littlefocus in regard to their suicide potential. This isthe clientele of our drug and alcohol services, whoengage in regular contact with counsellors ormethadone prescribers, and are enrolled (oftenrepeatedly) in detoxification or drug rehabilitationprogrammes, many of which are residential.Commonly their presentation to such servicesimmediately follows some personal crisis andhence they are likely to be in an emotionallyvulnerable state when suicide risk is peaking.Little is known about the self-harming outcome ofthis population as, in general, they are nottherapeutically pursued when they disengageprematurely, a common occurrence.

A related clientele is that which attends non-government refuges, half-way houses, and hostels.Staff of these organizations are even less skilled indealing with mental illness and have even lessaccess to psychiatric support.

These personnel may be aware of thesuicidality of their clientele but are often at a lossas to how to access appropriate mental heathattention. Sadly, when they do make approacheson behalf of their clients they may be met withdisinterest or encounter a discouraging barrage ofadministrative procedures which put the onus onthem to prove that their client qualifies for mentalhealth care, when really the need is often rather

24 • Australasian Psychiatry • Vol 7, No 1 • February 1999

obvious from the outset. In spite of all the years of emphasizing‘dual diagnosis’ in public health, funding in many areas remainshighly compartmentalized and these streams flow down to thecoal face so that ownership of the problem continues to bedisputed rather than shared. And strangely, mental healthprofessionals often feel their role in personal crises isinvalidated by the absence of psychosis or major affectivedisorder — a dangerously limiting point of view when death islurking. Happily there are some notable instances of effectivecollaboration.

Another important area, and one familiar with self-harmingbehaviour, is our general hospital emergency rooms. For manyyears experts have been drawing attention to the potential forimproved recognition and intervention in substance abuseproblems in emergency rooms [11], and the recommendationsremain worthy of promotion. Suicide attempters in emergencyrooms are more likely than other trauma cases to be intoxicated[10]. If an individual becomes dangerous to him/herself whenintoxicated, whether accidentally or deliberately, this mustsurely be a serious substance abuse problem meritingintervention.

SUGGESTED ACTIONWhat might be done to address these needs? The mostimportant factor will be the encouragement of co-ordination andco-operation at top administrative levels between Drug andAlcohol and Mental Health services. An understanding mustexist that the government backs a sensible approach to thiscompound problem, and is serious about dealing with suicide.Planning should be informed by treatment providers andconsumers from both areas of specialty. Ownership of theproblem in its various guises needs to be defined.

Such co-operation may be promoted by linkage projectssuch as Project Gemini [12] in the Inner City of Sydney, fundedby the Commonwealth Department of Human Services andHealth. In this project a team of dual qualified healthprofessionals established service linkages and educationalprogrammes between the integrated mental health service(including the psychiatric admission unit), drug and alcoholservices (including detoxification units and the methadoneprogramme), and local non-government establishments. Othermodels exist and have been implemented around Australasia; itis most important that the model suit the constituency and theprevailing administrative and service philosophy, achievingculture change at a tolerable pace.

It is highly desirable that formal mechanisms be set up toscreen for suicidality in clients of drug and alcohol services.This might mean for example a standard assessment at intakeand perhaps periodically and at times of crisis. Concurrentlyeducation should be provided to staff to upgrade their skillsallowing them to make use of the information from the screensand maintain vigilance for developing suicidality.

Complementary to the recognition of suicidality in drug andalcohol clients there must be procedures for responding. Alldrug and alcohol staff should receive training in basic aspects ofmanaging suicidality. However they should not be expected tocontain all the suicidality they encounter and again links withmental health services are important. Well-defined, streamlinedmechanisms will be necessary for psychiatric consultation to beprovided by designated individuals upon request, who canarrange for transfer of cases to mental health care whenappropriate. This should occur without having to waste timecajoling or arguing the point. The drug and alcohol serviceshould in its turn willingly provide ongoing specialistconsultation or co-management for transferred cases, and agreeto have them referred back if appropriate when psychiatricallystable. It would be an advantage to have designated liaison

persons with dual backgrounds acting as a link between the twoservices.

It is perhaps in the emergency department that most supportis needed to maintain a culture of suicide prevention. Patientswho are ambivalent or negative about maintaining their ownwell-being, i.e. substance abusers and self-harmers, are abusingthe sick role and are an embarrassment. They are likely toexperience ‘malignant alienation’ [13]. It is important to educatestaff about the need for proper prioritization of suicide risk, theappropriate place of paternalistic or coercive approaches, andthe great value of timely, effective intervention. Education mustbe repeated frequently for medical staff, who do the initialassessments after triaging, because they are rotated rapidlythrough the service. Important educational points include:• always consider and enquire about substance abuse when

assessing a suicidal patient;• always consider and ask about self-harm when assessing a

substance-abusing patient;• avoid sending suicidal persons away from the emergency

room for whom the suicide risk has not abated, or who arestill intoxicated;

• avoid disparaging or rejecting attitudes;• all intoxicated suicidal persons should be offered drug and

alcohol service assessment at some point.In the emergency room too support is needed from specialist

services, preferably integrated mental health service teams, whomust be available for rapid consultation. These teams in turnneed mechanisms available to them for resolution of dualdiagnosis problems without procedural uncertainty or turfconflicts.

Finally, at a primary prevention level, one might be boldenough to recommend that alcoholic beverages carry a warninglabel along the following lines: ‘This product should not betaken when depressed. Increases suicide risk.’

CONCLUSIONIn these times of interest in controlling national suicide rates,attention to the suicidal substance abuser is an obviousnecessity.

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