Diagnosis and treatment
Practical guidelines for the assessment and treatment of patients with SUDs have been published by the American Psychiatric Association (APA) and by the National Institute for Health and Care Excellence (NICE), and reported several forms of beneficial therapy including both somatic and psychological treatments.
The duration of treatment may vary, but to bring about changes in moderate alcohol use disorders it should not be less than six months. Treatment commonly lasts up to two years. It is important to maintain patient contact even if benefits are attained initially. When there is a risk of suicidal behavior, detoxification should take place on an inpatient basis and for a sufficiently long period.
Suicidal male alcoholics often consult general practitioners or emergency somatic departments for physical ailments. It is sometimes difficult for general practitioners to detect problematic alcohol and substance use if the patient is reticent. Structured forms, such as the CAGE questionnaire, may then be helpful. ‘CAGE’ stands for cut down, annoyance, guilty feelings, eye opener. The CAGE acronym refers to the four questions: Have you ever felt you should cut down on your drinking? Have people annoyed you by criticizing your drinking? Have you ever felt bad or guilty about your drinking? And have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (eye opener)? This questionnaire, which is not intimidating to the respondent, can be used as a possible rapid screening technique. Two or three positive answers are accepted as the criterion.
In dealing with suicidal alcohol users, a timeline follow-back technique, involving a systematic review of the past three months’ alcohol and drug consumption in terms of both pattern and quantity, is a helpful tool. Abuse and dependence is often unrecognized in female users (even though many of them are psychiatric patients), owing to women’s unwillingness to admit their alcohol habits and doctors’ lack of alertness.
Treatment must take into consideration the type and degree of substance use, the somatic status, psychiatric comorbidity, the level of social functioning, and problems in the spheres of life that are affected by those conditions. Measures may range from simple provision of advice or intervention to inpatient care, especially if there is an acute suicide risk.
Before an alcoholic is diagnosed as suffering from depression, the detoxification process should be completed. In the first few days of ‘detox’, some 60% of alcoholics show several depressive symptoms. After two weeks, only one patient in five shows signs of depression. Alcohol users should, therefore, be sober for at least two weeks before their need for antidepressant treatment can be assessed. On the other hand, for persons who have previously been diagnosed as depressed and who are at risk of suicide, antidepressant medication can be commenced earlier.
When alcohol users are treated with antidepressants, not only is their depression relieved but also their craving for alcohol diminishes. There are also studies that show that antidepressants can both remedy depression and prevent a relapse into misuse for drug addicts as well. However, pharmacological treatment must always be combined with psychosocial support and family interventions.
Case Study: Drug initiation, Ann-Marie, age 30
Small and slender, Ann-Marie tended to arouse intense caring feelings in others much of the time but periodically she was provocative, dismissive, and uncommunicative. Her mother had died of cervical cancer when Ann-Marie was 12. Her brother had started abusing drugs, and two years after their mother’s death he took his own life by shooting himself. It was Ann-Marie who found his body, and relating the experience still made her quiver with emotion. Her father, 20 years older than her mother and a fisherman by trade, became deeply depressed after his wife’s death and his son’s suicide, and he isolated himself completely. He was unable to take care of his daughter and took no interest in her schooling, social life, or future.
Ann-Marie had evidently undergone repeated periods of depression with a clearly seasonal pattern since her early teens. During these periods, she had experienced intense suicidal ideation and a pressing feeling that there was nothing to live for. Because of increasing loss of interest in her studies, she had failed to complete her compulsory nine years of schooling. The school psychologist, whom she had met more or less regularly, never diagnosed her depression.
At the age of 16, she had been employed as a nanny, but was dismissed as soon as the family found out that her boyfriend was a well-known drug addict. He introduced Ann-Marie to drugs and alcohol. She was then in contact with the social welfare office, which first arranged hostel accommodation for her and eventually found her temporary employment as an assistant in various shops. She never enjoyed these jobs, and was increasingly drawn into her boyfriend’s circle of associates and his drug-taking habits. Every time conflicts arose with the boyfriend or his associates, pitch-black, uncontrollable feelings of hopelessness and suicidal thoughts swept over her.
Between the ages of 18 and 20, Ann-Marie had been admitted several times to various services for drug use treatment, but she had always checked out after a brief stay and returned to the gang. Her life was constantly in chaos, with numerous people — from the psychiatric clinic, the social services, and the police — involved. Ann-Marie was unable to recall the names of various people who bore some kind of responsibility for her and it was obvious that she had not formed any strong ties with any of these carers, or vice versa. They all saw her as a hopeless case.
At the age of 20, she made four suicide attempts in six months. These suicide attempts were triggered by police interrogations that arose because of the involvement of Ann- Marie and her boyfriend Olle in drug trafficking and a burglary that he had roped her into while on parole from prison. A triangular drama that she was unable to resolve (involving herself, Olle, and a temporary boyfriend she lived with during Olle’s imprisonment) was another factor that contributed to her suicide attempts.
After the fourth attempt, when she had taken a large number of sleeping pills and was deeply unconscious for several days, she was treated at an intensive care unit. There she came into contact with a female psychiatric nurse, who identified with Ann-Marie’s problems and succeeded in motivating her to undergo a long-term cure at a treatment centre for drug users.
After several years of rehabilitation, Ann-Marie continued to have regular sessions with a psychotherapist. Ten years after the treatment, at the age of 30, Ann-Marie was still seeing the therapist a few times a year. She had a job she enjoyed, as an assistant nurse at an old people’s home. In her spare time she was committed to her voluntary work, helping to rehabilitate former teenage prostitutes. She was not married but had a steady relationship with a plumber of the same age as herself.
Suicide Theories: Psychodynamic and Escape Theories
Psychodynamic theorists have also provided accounts of suicide, beginning with Freud’s formulation of suicide as an act of aggression turned inward on the self, a view that was later elaborated by Menninger in his text Man Against Himself (Menninger, 1938). The conceptualization of suicide as a means of escape from psychological pain also figures prominently in psychodynamic accounts. In these accounts of suicide as escape, the act of self-harm is preceded by — and facilitated by — the breakdown of cognitive processes and the dissolution of the self.
A contemporary elaboration of the psychodynamic account, also informed by social and personality psychology theories and findings, was provided by Baumeister (1990). This theory describes a sequence of steps leading up to a suicide attempt as an escape from psychological pain. The first step in the sequence is the experience of a negative and severe discrepancy between personal expectations and actual outcomes (e.g., failures, unmet goals, disappointments). Second, the individual attributes this disappointment internally and blames him- or herself. Next, an aversive state of self-awareness develops, which produces negative affect. Next, the individual attempts to escape from this negative affect as well as from the aversive self-awareness by retreating into a numb state of cognitive deconstruction. In this state, meaningful thought about the self, including painful self-awareness and failed standards, is replaced by a lower-level awareness of concrete sensations and movements, and of immediate, proximal goals and tasks. This state of cognitive deconstruction results in reduced behavioral inhibition that contributes to lack of impulse control in general and especially a lack of impulse control for suicidal behavior. According to Baumeister, when individuals are in a state of cognitive deconstruction, thinking becomes constricted and myopic and the ability to identify alternatives to suicide as an escape from pain is impaired, thus increasing the likelihood of suicide attempts.
Selections from the books: “Suicide: an unnecessary death”. Edited by Danuta Wasserman. 2016; “The international encyclopedia of depression” Edited by Rick E. Ingram. 2009