Suicide risk in alcohol & other drug treatment settings: A persistent clinical issue
It has long been known that those entering treatment for substance dependence have high levels of psychopathology, a fact that will come as no surprise to anyone involved in drug treatment. In particular, large proportions meet criteria for a diagnosis of Major Depression, at rates far in excess of those seen amongst the general population. A good example of the extent of the problem facing clinicians is seen amongst heroin users of the Australian Treatment Outcome Study (ATOS) cohort, where a quarter of those entering treatment screened positive for Major Depression, a serious mental illness in its own right. Such figures are also seen for those entering treatment for other drugs, such as alcohol or methamphetamine. In a sense this is to be expected, given that, as many as three quarters of women entering treatment, and up to half of men, report histories of childhood abuse. There are also the harmful consequences of drug dependence on the person, and those around them, to consider. With such backgrounds, and the pressures of drug dependence, high rates of distress should be anticipated.
What has been less discussed, however, is suicide as a clinical issue for drug treatment agencies. Yet this is a major concern. Some 5-10% of dependent drug users die due to suicide. Our research consistently shows that around 40% of treatment entrants have a history of at least one suicide attempt, while something like a quarter will report current suicidal ideation. Both of these factors represent a heightened risk for future attempts as, indeed, does the Major Depression so frequently seen. While primarily treating the drug dependence of their clients, the risk of suicide is something that clearly needs careful monitoring in a drug treatment setting, with appropriate intervention provided where needed.
It was in this context that we conducted a needs analysis of Australian residential treatment agencies to see how suicide was being managed. Our results showed that a third of agencies had no formal policy on the management of suicide risk, and there was great inconsistency across those who did have policies. There was a clear need for a resource to aid agencies in managing this problem, which led us to develop the Suicide Assessment Kit (SAK) in collaboration with the Network of Alcohol and Drug Agencies. One myth we wished to address head on is that talking with a client about suicidality increases the risk of an attempt. This is simply not the case, and there is no evidence at all for such fears. As with other problems, not speaking about it does not make it disappear. The risk is still there. Given all we now know about the extent of the problem, a good picture of a client’s risk is a core clinical necessity, enabling that risk to be managed.
In order for staff to feel supported in assessing and managing suicide risk, it is essential that treatment services have clearly documented policies and procedures that are tailored for their organisation. One of the main benefits of putting these structures in place is that it gives staff a common language around the assessment and management of risk, and makes it easier to communicate with external support services. The SAK provides clear principles and guidelines to follow in developing these policies and procedures.
Treatment agencies face many challenges, and it is a credit to the hard work they do that their outcomes are so good. They do make a difference, and improve the quality of life of drug users. Suicide, however, is an issue lurking in the background that needs to be faced head on. Managing the risk amongst a high-risk population should be an integral part of the treatment system, no matter what primary drug problem the person presents with.