Addiction doctors, psychiatrists and other mental health and primary care providers frequently evaluate patients for depression, suicidal ideation, and intent. Experts have long known that previous suicide attempts are the most important factor in predicting future attempts. However, a new study by Bostick and colleagues (2016) reveals that previous research is wrought with methodological limitations (such as convenience sampling) and often overlooked first-attempt (index) deaths. The new findings reveal that deaths by suicide are nearly 60% higher than previously reported.

How did we miss this?

An innovative addition of this latest study may explain the discrepancy-index deaths. During the study period, 81 of the 1,490 enrollees (5.4%) died by suicide. Of the 81 completed suicides, 48 (59.3%) perished on index attempt; of the survivors (81.8%) killed themselves within a year.

Also, firearm deaths have increased but are predominantly categorized as death by suicide. Further, firearms were used in 75% of first attempt fatalities by men. Whereas fire-arms are used less often by women, the mortality rate, when they are used, is the same as men.

The first take home message is clear. The 12 months following a first suicide attempt is critical, as 80% of the subsequent deaths by suicide occur within this year—and, are strongly associated with the use of a gun. (odds ratio estimate of 140 (95% CI=60-325). The second message is actually good news. Survivors of first attempts were less likely to re-attempt within 12 months when they had a follow-up appointment scheduled upon discharge, even if the appointment was not actually kept. (odds ratio=0.212, 95% CI=0.089-0.507).

As clinicians, these findings are important for several reasons: 1) Suicide prevention efforts should start BEFORE the first attempt, as nearly two-thirds are fatal. 2) The use of a firearms continues to be the most lethal modality in suicides. Accordingly, depression, coupled with easy access to a firearm, is associated with increased mortality by suicide. 3) Follow-up appointments resulting from a failed suicide attempt should be locked in place prior to discharge from the healthcare facility, and 4). Because the 12 months immediately following a first attempt is critical, aggressive psychiatric care and psychosocial management, including access to treatment prevention resources, are absolutely essential.

Why Does This Matter?

As the concordance rate between depression and substance use disorder is over 50%, addiction professionals must assess and identify depression, past suicide attempts, and current suicidal ideation during any and all treatment events. At present there remains some controversy among addiction professionals regarding the necessity and efficacy of treating co-occurring mental illness during primary addiction treatment. Some argue that once the addiction is managed the depressive symptoms will subside—inferring a causal relationship between addiction and depression. Others believe in a co-occurring model, which asserts that it doesn’t matter which came first, both must be treated aggressively. Although we practice amid this tension, we cannot forget that the cost of untreated depression is too high. Suicide is now the second leading cause of death among teens and young adults. The mortality rate of untreated or underrated depression for adults is over 15%.

What should we do? Highly trained addiction medicine doctors and addiction psychiatrists are essential in identification of depression and suicide risk for patients with substance use disorders. More training and innovative treatment modalities for individuals with depression and dual disorders are necessary.