Not all substance abusers manifest suicidal behavior, but too many do. A CDC toxicology study of suicide victims found over one-third positive for alcohol and just under one-fifth positive for opiates. These substances did not cause these suicides, but they likely added to the victims’ risk. Most family members of individuals who abuse alcohol and other substances are aware that this behavior can lead to suicide. They may become familiar with their thoughts and threats of suicide, and, in some cases, suicide attempts. Yet few may have much insight into how suicidal behavior is associated with substance abuse.
What is suicidal behavior?
Suicide is caused by a self-inflicted injurious act with intent to die. Suicide is a planned outcome of a desire to end one’s life. Explicit intent to die is what sets suicide apart from non-fatal self-injury (e.g., cutting) or intentional overdoses.
Suicidal behaviors are activities related to suicide and include:
- Suicidal Ideation – Thoughts of attempting or completing suicide.
- Suicide Threat – An expression of intent to attempt or complete suicide.
- Suicide Plan –When, where, and how an attempt will be made.
- Suicide Attempt – An intentional effort to die by suicide that was not fatal, and which may not result in injury.
Risk increases exponentially as an individual proceeds along this continuum.
What about suicide threats?
A suicide threat is a signal of potential suicide risk. It may be verbal or nonverbal. Threats may not necessarily be made. However, even when they are, suicide threats may not always reflect any thought of death. Consider these two threats:
“I am going to kill myself tonight by [insert lethal means].” “I will kill myself tonight if you make me leave.”
The first is an unconditional statement with a plan, timeframe, and means. The second is conditional and “sets the terms” under which “intent” may be acted on. Conditional suicide threats are probably the most common suicidal behavior experienced by family members. They tend to be heard when the substance abuser is losing control of an interpersonal situation or facing other adverse circumstances.
Family members need to understand both types of suicide threats but leave it to mental health professionals to determine which is which and to respond appropriately. Suicide threats are a major danger sign and must never be ignored or minimized. Even the most apparently manipulative “suicidal” substance abuser has many risk factors and may constitute a potential danger to self or others even in the absence of suicide intent. Conditional threats are best discussed after the safety of all parties is assured.
How does someone become suicidal?
Thomas Joiner, PhD, a psychologist at Florida State University, developed a widely accepted model known as the “Interpersonal Psychological Theory of Suicide.” It proposes two prerequisites to a potentially lethal suicide attempt: (i) an extremely strong desire to die; and (ii) the capability for lethal self-harm. An intense desire for death arises in a strong belief that one is a burden to others and/or the belief that one does not belong. The capability to try to take your life requires overcoming the instinct for self-preservation. This can occur through experiences that inure you to fear or pain.
The lifestyle of most substance abusers offers many opportunities to meet Joiner’s prerequisites for a suicide attempt. The ability to fulfill personal responsibilities to
others and meet even their minimal expectations is gradually lost and with it the support and meaning that interpersonal relationships provide. Most forms of substance abuse involve some degree of self-harm (e.g., IV drug use). Exposure to violence is a common. Suicidal ideation about intentional overdoses often plague substance abusers. Constantly thinking about such acts increases susceptibility to carrying them out. Some rehearse their suicide plan by holding a weapon, visiting a bridge, or walking by railroad tracks. This adds to capability.
How does substance abuse drive suicide risk?
Substance abuse is more than a risk factor. It is a facilitator of suicidal behavior. Alcohol and drug use worsen almost everything that should be minimized in a suicidal individual. They significantly enhance impulsivity, hopelessness, aggression, disinhibition, poor judgment, blunting of the senses, and pain tolerance. Problem-solving and coping skills are impaired as is understanding future consequences. All or nothing thinking tends to prevail. Most substance abusers already have multiple suicide risk factors such as male gender, serious legal issues, financial problems, unemployment, co-occurring mental illness, a history of trauma, and worsening physical health. Some of these may pre-date alcohol or drug use, but all are amplified by it.
What are the signs of suicide risk?
There is no standard presentation of emerging suicidality. Some early warning signs may include:
- Talking about losing control or being trapped
- Withdrawal from family, friends, treatment, work, or school
- Anxiety, agitation, sleep problems
- Mood changes, anger, panic, pessimism
- Growing self-criticism
- Increasing use of alcohol or drugs
Some possible signs of rising risk are:
- Escalating impulsivity, risky and negative behavior
- Indifference to favored activities or interests
- Being present-oriented and vague on future
- Giving away pets or valued possessions:
These are clearest indicators of possible imminent dangerousness:
- Threats to severely injure or kill self
- Looking for, acquiring, or having lethal means (e.g., gun, pills, poisons, etc.) poisons, etc.)
- Voicing a specific suicide plan
Family members should always opt to err on the side of caution when any signs are observed.
What can family members do?
Some preventive measures are supporting sobriety and recovery (the best buffers to suicidality), discarding or securing any prescription or OTC medications, and encouraging contact with a behavioral health provider at the earliest sign of suicidality. Be vigilant after a death in the family or of a peer, after a psychiatric hospitalization, and after a relapse. Prepare and share a family suicide prevention plan outlining any medical or behavioral health providers to call, other family members or friends who can help, local emergency service numbers, and include these actions if suicidal behavior is felt to be present:
- Directly ask about thoughts of suicide
- Ask if a suicide attempt is being considered
- Ask if anything has been done (if yes, 911)
- Say that you care and want to help
- Do not let the person leave or be alone
- Try to restrict access to lethal means (if this can be done safely)
- Urge contact with a hotline, crisis center, or emergency department
- Call 911 if voluntary assistance is rejected
- Do not hesitate to pursue an involuntary psychiatric evaluation
Remember that suicidal behavior may abate but suicide risk endures and suicidality may resurface. Always maintain prevention mode.
Tony Salvatore is on the staff of Montgomery County Emergency Service, a nonprofit crisis psychiatric service in Norristown, PA. He may be contacted at firstname.lastname@example.org.