Predictors of a suicide attempt one year after entry into substance use disorder treatment.

Background: The present study examined the patient intake and treatment-related risk factors associated with a suicide attempt in the 30 days before a 1-year post-treatment assessment.

Methods: A national sample of 8,807 patients presenting for treatment of substance use disorders (SUD’s) in the US Department of Veterans Affairs healthcare system were assessed at treatment intake and follow-up.

Using the MacArthur Model, the risk and protective factors for suicide attempt were identified at baseline and during treatment.

Results: At follow-up, 4% (314/8,807) of the patients reported a suicide attempt within the past 30 days.

Baseline predictors of a suicide attempt before follow-up included

• elevated suicidal/psychiatric symptoms,
• more recent problematic alcohol use, and
• longer duration of cocaine use.

Contact with the criminal justice system was a protective factor that reduced the likelihood of a future suicide attempt.

Greater engagement in SUD treatment was also associated with a reduction in suicide risk.

Conclusions: More involvement in SUD treatment reduced the likelihood of a future suicide attempt in high-risk patients.

Substance use disorder treatment providers interested in reducing future suicidal behavior may want to concentrate their efforts on identifying at-risk individuals and actively engaging these patients in longer treatment episodes.

Research report; Predictors of a suicide attempt one year after entry into substance use disorder treatment. Ilgen MA, Harris AH, Moos RH, Tiet QQ. Alcohol Clin Exp Res 2007; 31(4): 635-42.

See also;

• Strategies for Dealing With Crises
• Brief-TSF is designed to address these issues.

Alcohol and Suicide: Research and Clinical Perspectives by Leo Sher, Isack Kandel, Joav Merrick Read more about this title…

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The Co-Occurrence of Depression and Alcohol Dependence Symptoms in a Community Sample of Lesbians

Numerous studies have found an association between depression and alcohol use disorders in women.

Little is known, however, about the relationship between depression and alcohol use among lesbians.

We examined the prevalence of depression and alcohol dependence symptoms as well as the co-occurrence of these two health problems in a large community-based sample of women who self-identified as lesbian.

Past year alcohol dependence symptoms were significantly associated with both past year and lifetime depression.

Lifetime depression was higher among White and Latina lesbians than among African American lesbians.

Younger women and those not currently in a committed relationship more commonly reported past year depression.

Younger age was the strongest predictor of the co-occurrence of depression and alcohol dependence symptoms.

Research report; Wendy B Bostwick, Tonda L. Hughes & Timothy Johnson. The Co-Occurrence of Depression and Alcohol Dependence Symptoms in a Community Sample of Lesbians. Journal of Lesbian Studies, Volume: 9 Issue: 3, 2005

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Simple Screening Can Help Decrease Teen Risk Behaviors

Research shows that adolescents who engage in one form of risky behavior, like drug or alcohol use, are likely to engage in other risky behaviors like self-harm, or having unprotected sex, but often times these behaviors are not discussed during a medical or mental health exam. Now, a new study shows that a simple and brief screening measure called the adolescent risk inventory (ARI) can quickly identify the broad range of risk behaviors found among adolescents.

“This constellation of behavior problems is really the thing we are trying to avoid. So, identifying early that a teen is engaging in a risky behavior may prevent that behavior from being the gateway to further risky behaviors,” says lead author Celia Lescano, PhD with the Bradley Hasbro Children’s Research Center and The Warren Alpert Medical School of Brown University.

This research study appeared in the April 2007 issue of the journal Child Psychiatry and Human Development.

Prior research indicates that teenagers who engage in one risky behavior are more likely to be involved in others and that this has an additive effect. The authors note that risk behaviors among teens are prevalent and can lead to increased morbidity, mortality, and health care costs, so identifying and dealing with problematic issues as they arise can help teens be safer and healthier.

Researchers studied 134 youth ages 12 to 19 with psychiatric disorders. Each study participant was given the adolescent risk inventory (ARI) (a paper and pencil measure). The ARI included questions about sexual history (have you ever been pregnant or been a dad?), self-harm (have you ever attempted suicide?), and attitudes towards acting out (do you break rules for no reason?).

“We found that the ARI is reliable and comprehensive and can be useful in quickly identifying a wide range of teen risk behaviors,” says Lescano.

This is important, the authors say, because when teens are seen for medical and/or mental health care, risk behavior issues are often neglected. Time and relevance are often seen as barriers that prevent providers from obtaining this important information.

“Given that the ARI is brief and broad in it assessment of behaviors, these barriers can be overcome and allow pediatricians, family doctors and mental health professionals to make referrals based on the information they get from the teen,” explains Lescano.

The analyses also provided intriguing data on the relationship between sex risk, psychopathology, and behavior in that abuse or self-harm behaviors were highly predictive of sex risk. This is important because while many clinicians are aware of the sexual risks that aggressive youths take, many are unaware of the association between risky sexual behavior and emotional distress, abuse and self-harm. Behaviors like self-cutting thoughts, suicidal thoughts or attempts, or a history of sexual abuse should alert clinicians to the potential for significant sexual risk, the authors say.

Oftentimes, research programs that target the identified risk behavior can be found in nearby communities or even through the medical or mental health offices in which the teens are being seen.

“Referral to these programs, as well as to mental health professionals to help treat the negative emotions that can precipitate risk behaviors may be useful avenues to decreasing risky behaviors in teens,” says Lescano.

Research report from; Lifespan

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Spiritual assessment in biomedicine

The recent surge of interest in links between spirituality and health has generated many assessment approaches that seek to identify spiritual need and suggest strategic responses for health care practitioners.

The interpretations of spirituality made within health frameworks do not do justice to the way spirituality is understood in society in general.

Spiritual assessment should not impose a view or definition of spirituality, but should seek to elicit the thoughts, memories and experiences that give coherence to a person’s life.

Spiritual assessment tools should not be used without adequate exploration of the assumptions made. Assessment processes need to be adequately conceptualised and practically relevant.

In agencies organised according to biomedical priorities, spirituality is a personal coping mechanism that need not be incorporated into the health treatment plan.

Integration is the patient’s issue – patients must work out how to incorporate their experience of the biomedical system into the rest of their lives.

Social perspectives that regard spirituality as a means of social support view spiritual care as the responsibility of the cultural and religious communities supporting the patient.

Practitioners operating within a social model may be more intentional about involving these communities in care, but they still leave the decision to participate to the patient and family.

In both these approaches, it is for patients to decide whether they will seek spiritual care alongside the health care being provided.

However, spiritual care may be seen differently within a biopsychosocial framework. Here spirituality is related to quality of life and is thus one of the individual characteristics that shape health beliefs and motivations. It affects compliance and outcomes, and is thus legitimately an area of interest for clinicians.

Criteria for appropriate spiritual assessment

Spiritual assessment should thus not impose a view, let alone a definition, of spirituality, but should seek to elicit the thoughts, memories and experiences that give coherence to a person’s life. This implies taking seriously the idea that spirituality preserves identity and sense of self, particularly in professionalised environments, and ensuring that professional practice assessments are made within a framework that matters to the patient.

This means identifying spiritual needs and resources in ways that

• Respect patients’ perspectives and do not infringe privacy;
• Involve all members of the interdisciplinary team to the extent that they are able and willing to contribute;
• Permit clear documentation of needs, strategic responses to these needs, resources required, and outcomes;
• Integrate strategies into an overall care plan in ways that are readily understood by all members of the interdisciplinary team;
• Provide a shared framework for continuity of care between community agencies and inpatient services; and
• Provide a place for religious care but do not conflate spiritual issues with religious practice. While spiritual care in general may be provided by a team, specific religious care is best provided by a person from the same faith community, preferably one willing to participate in the team.

Appropriate process for spiritual assessment

Spiritual assessment must be a process, not merely an event, as it needs to take account of emergent insights and accommodate the patient’s exploration of particular issues if he or she so chooses.

The discussion here applies to health care contexts in which process is possible (such as general medical practice, community health or residential care), rather than the brief encounters of day surgery or the emergency room.

The process should begin with a form of screening, preferably one that maps significant relationships within the domain of spirituality. This screening can be carried out descriptively, noting connections as they emerge in taking patient histories and in general clinical and informal encounters by all members of the team.

For more information see; Bruce D Rumbold. A review of spiritual assessment in health care practice. Medical Journal of Australia 2007; 186 (10): S60-S62

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Care is poor, despite the existence of proven therapies.

Evidence-based practice guidelines clearly state that patients at risk for alcohol withdrawal should be monitored and treated with benzodiazepines if their risk is high enough or symptoms are substantial. In a retrospective record review, researchers evaluated whether a protocol for such an approach — symptom-triggered therapy — was followed appropriately at two large general hospitals that offer more than 40 specialty services. The protocol — the Revised Clinical Institute for Withdrawal Assessment for Alcohol (CIWA-Ar) — employs a symptom assessment that required patients to be able to communicate.

Of 124 inpatients who received symptom-triggered therapy, more than half (52%) were treated inappropriately: 35 had no recent heavy alcohol use and therefore were not at risk for withdrawal, 9 could not communicate well, and 20 had no recent heavy drinking and were unable to communicate. Overall, 11 patients had adverse outcomes (i.e., seizure, delirium, death); 7 of them had received inappropriate treatment.

Comment: People who have not been drinking heavily recently cannot, and should not, be treated for alcohol withdrawal. People who cannot communicate can, and sometimes should, receive withdrawal treatment but not if the decision is based on a symptom scale that requires verbal communication. We should take notice when only half the people with a potentially fatal condition receive appropriate treatment. Known effective treatments exist for alcohol withdrawal, and they are quite straightforward. If the hospitals in this report represent U.S. hospitals generally (as is likely), we have a large challenge to implement appropriate care for this common condition.

Research report; Hecksel KA et al. Inappropriate use of symptom-triggered therapy for alcohol withdrawal in the general hospital. Mayo Clin Proc 2008 Mar; 83:274.

See also;

• Twelve-Step Programs as an Adjunct to Psychotherapy and Psychopharmacology

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