Each year the 10 September marks World Suicide Prevention Day. John Robins outlines why this issue remains important for addiction treatment services and for people who use drugs. He also discusses what steps can be taken to help prevent suicide.
Despite a general decline in suicide rates in most countries since 2000, suicide still accounts for more deaths annually than malaria, HIV, breast cancer or homicide (World Health Organization, 2021). Roughly 17 people per day die by suicide in the UK, and an estimated ten to thirty times as many people attempt it. The link between addiction and suicide is well established, with alcohol or opioid dependent people having an estimated 10 to 14 times greater risk of suicide than the general population; especially concerning given the ubiquity of alcohol. One study that particularly struck me followed over 3,000 people in Sweden over 50 years, and found that among alcohol-dependent men with depression, just under 17% died by suicide. These men with comorbid alcohol use and depression were the group at the highest risk of suicide overall (Holmstrand et al., 2015).
As well as engaging people in treatment we can ask about suicide, and ask regularly. Drug workers know about transient overwhelming feelings; helping people to ride out the waves of their cravings is part of day-to-day work.
Suicide risk is dynamic
It is no surprise that people who access substance use treatment services have a greater risk of suicide, and will often be battling with a wide range of suicide risk factors on top of the risk conferred by the drug use alone; poly substance use, tobacco use, depression, unemployment, poverty, stress, criminality, isolation.
However, what is perhaps surprising is just how transient the desire to die can be, and this transience seems to be amplified especially where alcohol use is involved. We looked at suicide in people detained by police because they were in the process of trying to kill themselves and most of them felt much better the next day, and this was especially common in those who had drunk alcohol before their suicide attempt (Robins et al., 2021). Suicidal intent can emerge, resolve and return remarkably rapidly, and this dynamic needs to be recognised in our efforts to prevent it.
Treatment for addiction
Drug workers can help to prevent suicide. Simply engaging people in treatment can help decrease the risk of suicide – not only through medication to stabilise withdrawal but also through developing support and networks of people in recovery to reduce the sense of isolation and alienation that contributes to suicide. Fostering this social connectedness builds a hugely important protective factor. For example, recent ONS statistics for England and Wales confirm that in the first 3 months of lock-down in 2020, the numbers of suicides were lower than in the same period over the previous 3 years. This may seem surprising but I suspect reflects the community cohesion that emerged during those first few months of lock-down.
As well as engaging people in treatment we can ask about suicide, and ask regularly. Drug workers know about transient overwhelming feelings; helping people to ride out the waves of their cravings is part of day-to-day work. But the safety plans psychiatrists and psychologists make with people in suicidal crisis aren’t so different from the plans drug workers make with people to cope with cravings. So, don’t be scared to ask about suicidality – like cravings it is a part of patients’ experience and talking about it won’t increase the chance of acting on it.
Getting timely support for suicidal thinking is the important thing – because like craving, the urge can appear quickly, become overwhelming, and be acted upon. So, ask; and ask frequently, particularly when social circumstances are difficult, relationships have broken down, or when mental health problems seem worse.
Workforce skills
Effective and evidence-based training can help everybody to understand suicide, and to be more confident in working with suicidality. It can help us to know what questions to ask, and how, and when to do so. It can help us to avoid overreacting or underreacting to someone talking about suicidal intent. Even implementing simple safety planning interventions can help by presenting alternative coping strategies and sources of support, as borne out in the findings of a recent meta-analysis. (Nuij et al., 2021).
Most importantly is not underestimating the effect we can all have upon those we work with, as is beautifully encapsulated by this quote from someone who suffered a lot from suicidality, and who’s words reflect the power of keyworking done well.
“I remember sitting in his office a hundred times during those grim months and each time thinking, What on earth can he say that will make me feel better or keep me alive? Well, there never was anything he could say, that’s the funny thing. It was all the stupid, desperately optimistic, condescending things he didn’t say that kept me alive; all the compassion and warmth I felt from him that could not have been said; all the intelligence, competence, and time he put into it; and his granite belief that mine was a life worth living.”
― Kay Redfield Jamison, An Unquiet Mind: A Memoir of Moods and Madness
Holmstrand, C., Bogren, M., Mattisson, C., Br, L., 2015. Long-term suicide risk in no, one or more mental disorders : the Lundby Study 1947–1997 459–469. https://doi.org/10.1111/acps.12506
Nuij, C., Van Ballegooijen, W., De Beurs, D., Juniar, D., Erlangsen, A., Portzky, G., O’Connor, R.C., Smit, J.H., Kerkhof, A., Riper, H., 2021. Safety planning-type interventions for suicide prevention: Meta-analysis. British Journal of Psychiatry 219, 419–426. https://doi.org/10.1192/bjp.2021.50
Robins, J.E., Kalk, N.J., Ross, K.R., Pritchard, M., Curtis, V., Morley, K.I., 2021. The association of acute alcohol use and dynamic suicide risk with variation in onward care after psychiatric crisis. Drug Alcohol Rev. 40, 499–508. https://doi.org/10.1111/dar.13231
World Health Organization, 2021. Suicide worldwide in 2019: global health estimates. World Health Organization, Geneva.
John Robins is a substance misuse practitioner and PhD student at King’s College London researching alcohol use and suicide risk in crisis care.
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