Richard H. Weisler, MD; Ashwin Patkar, MD, MRCPsych


June 03, 2010

This feature requires the newest version of Flash. You can download it here.

Substance Abuse and Suicide at APA: Introduction

Richard H. Weisler, MD: My name is Rick Weisler. I'm a practicing psychiatrist in North Carolina and also Adjunct Professor of Psychology at University of North Carolina, Chapel Hill, and Adjunct Associate Professor at Duke University. I'm joined today by Dr. Ashwin Patkar, director of the addiction service program at Duke and also Associate Professor at Duke.

We're going to talk today about a couple of APA presentations on suicidality and suicide, as well as information on drug and alcohol abuse in some of these new research papers. Ashwin, why don't you start off with one of the topics?

Mortality in Substance Abuse

Ashwin Patkar, MD: I was interested in discussing a poster looking at mortality [in patients] failing treatment for cannabis, cocaine, amphetamine, ecstasy and opiate use disorders -- a study from Denmark which was done by Dr. Jensen[1] and others. They looked at a large cohort of over 20,000 individuals who are in treatment for illicit substance use. They calculated the ratios for mortality, which were standardized with respect to their age and genders.

They found that the mortality ratios for cannabis, in particular, were significant -- 4.9 to be precise, along with cocaine which was 6.4, heroine which was 9.1, and prescription opiates which was 7.7. The point about this paper was that there has been a debate back and forth about cannabis -- to what extent it's harmful and to what extent it has an addictive potential.

The study clearly showed that use of cannabis was associated with increased mortality.

Dr. Weisler: A lot of doctors feel that cannabis is not really a problem, that potency is not really an issue. What are your thoughts on this?

Dr. Patkar: There are very strong data that cannabis has consequences on the brain which are harmful, in particular on memory, and that it is especially harmful for patients with psychiatric disorders -- those who have schizophrenia, bipolar disorder, other substance use disorders, as well as depression.

Dr. Weisler: I would say that ADHD can be an issue as well and can affect mood and depression and lead to other things. So the mortality rate goes up. It may not be as benign as a lot of people might think.

Dr. Patkar: Yes, certainly more research needs to be done. I would be curious to see whether they could look at the association between mortality rates and comorbid psychiatric disorders.

Suicide and Rurality

Dr. Weisler: I want to now take a look at suicidality for a minute. There was an interesting presentation on morality and suicide. In other words, what happens if you live in a less densely populated area?

This was a poster [presented] by Dale D'Mello at Michigan State.[2] The [investigators] knew there [was a higher prevalence of suicide] in rural areas for and they wanted to look at that. So they went through looking at deaths per 100,000 from the National Center for Health Statistics and the Census Bureau.

They looked at all the states for the 2004 and they found that Alaska, the state with the lowest population density (1.2 people per square mile) had the highest suicide rate at 23.1 per 100,000 population, compared with a US [national] rate of around 11 per 100,000 population.

Conversely, the District of Columbia, which has the highest population density (9316 people per square mile) had the lowest suicide rate of 5.3 deaths per 100,000 people. So there definitely was an overall powerful negative correlation observed between suicide rates and population density.

The other issue that we need to address is the issue of access to care. As the author suggests, this may be a relative factor in rural areas; "telehealth" may bridge the current gap, but there's a lack of resources [in these areas]. Any thoughts about that, Ashwin?

Dr. Patkar: Yes. At least in the state of North Carolina where we both practice, over 70% of the rural counties have a shortage of psychiatrists, in particular child and adolescent psychiatrists. There's definitely an association between untreated mental illness and suicide rates. So I do feel that this could be one of the factors [contributing to] the increased suicide rates.

Dr. Weisler: Especially depression. Depression increases the risk very dramatically, for sure, and as you were talking about, we know that 40 counties out of 100 in North Carolina don't have a child psychiatrist. So there is a real access problem there. And it's not just North Carolina. It's in the Midwest, the West, even in the Northeast -- there's a shortage of providers.

I would be remissnot to say there's a real shortage of providers in military mental health as well. The suicide rate in the Marines is higher than combat deaths in Iraq and Afghanistan [and also very high in] the Army.

Dr. Patkar: Rick, do you think there's an opportunity for telemedicine to play a role?

Dr. Weisler: There may well be an opportunity for telemedicine to play a role. I certainly don't have expertise in that area, but I know the VA is doing some research looking at that. There are clinics in North Carolina and around the country, as I've gone lecturing, where I see people working from an office trying to reach out and provide primary care doctors, mental health specialists, etc. in rural areas with that special expertise [which will] hopefully address this risk. Untreated depression, bipolar disorder, and ADHD dramatically increase the risk [for suicide], as does substance abuse.

Mental Illness and Substance Abuse in Young Suicide Victims

Dr. Weisler: There is a study by Dr. Yildirim, who is in North Carolina as well -- East Carolina University in Greenville -- and Dr. Bloch.[3] They explored mental illness and substance abuse and how they vary among children and adolescents who commit suicide.

We know that suicide is the third leading cause of death in children under 18, after unintentional injury and homicide. But there is a significant relationship there.

Out of the 234 victims they looked at from1999 to 2008, they found that mental illness and/or substance abuse was present in 51% of the people who died. You might want to comment about that for a minute.

Dr. Patkar: This, I think, underscores the fact that the combination of a mental illness and substance abuse in the adolescent population is, without exaggerating, a potentially lethal combination.

Dr. Weisler: You're right.

Dr. Patkar: You and I know about several cases of patients who suffer from this combination who actually attempted suicide, and sometimes, unfortunately, have been successful.

Dr. Weisler: Right. There's a big study for readers and viewers to look at done by SAMSA[4] [which reviewed] suicidality back in 2003. They looked at people who came to emergency rooms. If you had substance abuse problems -- including alcohol abuse -- on top of [other] problems, the risk went way, way up.

Looking at children and adolescents, depression was the number-one mental illness seen among suicide victims, [occurring in] 29% of the cases in that study, followed by disruptive behavior disorder which [occurred in] 10.6%.

In conclusion, depression is the biggest risk factor, present in at least half of the cases. People need to be aware that it affects all races, including both genders, and is very important to address.

Substance Use and Trauma

Dr. Patkar: Another study looked at the relationship between substance use and trauma by reviewing charts of patients who were admitted to trauma centers. It was conducted by Dr. Houchins[5] from the University of South Carolina. The group looked at over 2000 surgical patients.

Dr. Weisler: Surgical trauma -- so it's not just suicide, it's not poisonings.

Dr. Patkar: Yes. They looked at close to 800 charts (and plan to study 2000) examining blood alcohol levels, urine tox screen results, as well as mechanisms of injury and outcomes, such as Glasgow Coma Scales. What they found was that the percentage of people with trauma who tested positive for alcohol was around 40%, and those who tested positive for at least 1 drug on the urine drug screen was 55.6%. Younger age was a significant factor in both the alcohol- and drug-positive groups, as was male sex for the alcohol group.

Dr. Weisler: Right. Again, we know that so many parents and families have lost loved ones to accidents. They may take their own lives in these accidents, but they may also take other people's lives when they run into somebody else or have a friend in the car. So it's clearly a major public health problem for people.

Dr. Patkar: Yes. Along those lines, at Duke, we have implemented a program in trauma centers and the emergency room called Screening and Brief Intervention. You always have a standardized system to screen every patient with trauma for substance use. If it's detected, you can implement what's called a Brief Intervention, which is supported by National Institute of Alcohol and National Institute of Drug Abuse, as an evidence-based treatment.

Dr. Weisler: That's very critical information -- not only for doctors, but also parents [who should] be aware of what's going on with their kids. But it's not just kids; it's all ages. These accidents unfortunately affect people all the way into the elderly age groups, throughout the entire age range.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.