Substance Abuse

Substance use disorders are second to mood disorders as the most common risk factor for suicide (Chapter 3). Substance abuse is an especially important risk factor for suicide in young adults (Chapter 3). Furthermore, substance abuse and mood disorders frequently co-occur, with 51 percent of suicide attempters having both (Suominen et al., 1996). Treatment of co-morbid alcoholism and depression with selective serotonin reuptake inhibitors (SSRI) reduces suicidality (Cornelius et al., 2000; Cornelius et al., 2001). Thus, detection and treatment of substance abuse and depression in primary care is important for suicide prevention (Murphy, 2000; PHS, 2001).

For the primary care setting, numerous professional groups recommend routine detection of problem drinking in all patients, as well as brief counseling for non-dependent problem drinkers (summarized in US Preventive Services Task Force, 1996). Nevertheless, problem drinking often goes undetected in primary care. In recent surveys, about 40 percent of primary care physicians do not perform routine screening for substance abuse (Bradley et al., 1995; Williams et al., 1999). The most commonly cited reasons are lack of time and fear of spoiling the relationship with the patient (Arborelius and Damstrom-Thakker, 1995).

For detection of drug abuse in primary care, professional guidelines diverge from those for problem drinking: they generally do not recommend screening all primary care patients for drug abuse. However, clinicians are recommended to be alert to signs and symptoms and to refer drug-abusing patients to specialized treatment (US Preventive Services Task Force, 1996). Standardized screening questionnaires are thought to be too insensitive to identify potential drug abusing patients. In a recent shift, arising from concern about suicide, the Surgeon General’s National Strategy (PHS, 2001) sets as national objectives screening for substance abuse, depression, and suicide risk in federally-supported primary care settings (e.g., via Medicare and Medicaid) and the use of such screening as performance measures for managed health care plans. A later section deals with the treatment of substance abuse, with or without a co-occurring mental disorder, because it is reserved for specialty care (US Preventive Services Task Force, 1996).

Primary Care Barriers to Detection of Suicidality

It is well established that a large proportion of suicide victims are not detected in primary care in the days before suicide. A systematic review of published studies found that, in the week before death, contact with primary care was made for 16–20 percent of completed suicides. Within



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