Does treatment setting influence suicide rates for substance abusers

Reported rates of suicide attempts by individuals with substance-use disorders (SUDs) range from three percent in the previous 30 days to lifetime rates of 45 percent.

Despite this relatively high frequency of suicide attempts by substance users, the effects of treatment following a suicide attempt are not well understood. A study in the September issue of Alcoholism: Clinical & Experimental Research investigates if treatment setting - inpatient or outpatient - has a different impact on outcomes for suicidal and nonsuicidal patients with SUDs.

"Historically, substance-abuse treatment was usually provided in inpatient settings," explained Mark A. Ilgen, a researcher at the Department of Veterans' Affairs (VA) Palo Alto and corresponding author for the study. "During the last few years, there has been a push to expand treatment options into more outpatient settings, largely as a cost-containment measure. Once that started, people began to ask: 'well, if it seems to work in outpatient settings, why even provide inpatient treatment?' So the pendulum has swung from being very focused on inpatient treatment to now being more focused on outpatient treatment. This may not be beneficial for certain groups, prompting the question: 'for whom is the treatment setting either more or less important?'"

As part of his post-doctoral studies at the Palo Alto VA, Ilgen and his co-authors examined a national sample (n=1,289) of patients receiving SUD treatment through the VA healthcare system. Participants provided information on their psychiatric and substance-related problems both at baseline and at an average of six months following treatment.

The study found that those individuals who reported a suicide attempt were no more likely to be treated in an inpatient than in an outpatient setting. However, suicidal patients who received inpatient, compared to outpatient, SUD treatment were significantly more likely to have better substance-related outcomes at follow-up. Suicidal patients who were given inpatient, compared to outpatient, SUD treatment did not have better outcomes on psychiatric symptoms.

"These findings have several implications for treatment," said Ilgen. "First of all, substance-abuse treatment providers - both inpatient and outpatient -are likely to see patients who have recently made suicidal attempts, so they should have some way of adapting to those patients. Additionally, these findings suggest that more intensive treatments may be particularly helpful for suicidal patients with SUDs."

Kenneth R. Conner, assistant professor of psychiatry at the University of Rochester Medical Center, concurs. "The data reinforce the importance of considering a recent suicide attempt in treatment planning," he said. "A recent suicide attempt is the single best predictor of a subsequent act of suicide, underscoring the critical need to link substance-dependent individuals making a recent suicide attempt to adequate treatment services."

However, noted Conner, "inpatient treatment did not result in better outcomes on psychiatric symptoms than outpatient treatment among suicide attempters. Suicidal behavior among substance abusers is strongly influenced by psychiatric symptoms, particularly depression, and so caution is needed in concluding that inpatient treatment resulted in superior outcomes, at least as concerns suicide risk." He suggested that future research examine the extent to which psychiatric symptoms/problems are addressed in inpatient and outpatient substance-abuse treatment.

Both Ilgen and Conner said that this study shows that certain populations clearly benefit from inpatient treatment.

"These findings serve as a reminder that there is a place for more intensive treatment," said Ilgen, "that outpatient treatment is a positive thing, but we shouldn't overact and decrease the availability of inpatient treatment before we know for whom that more intensive treatment might be more beneficial."

"It appears problematic to include individuals who have made a recent suicide attempt in outpatient care," agreed Conner. "Recent suicide attempters, as well as other select patient populations such as substance abusers who also have a major psychiatric illness, may benefit more from inpatient care."

Ilgen hopes that these findings will not only encourage treatment providers to assess for both suicidality and substance use in their patients, but also encourage them to refer the suicidal patient to SUD treatment or even provide SUD treatment for them. "One should not immediately conclude that a suicide attempt precludes these individuals from SUD treatment," he said. "A suicide attempt is often perceived as being so glaringly important that it overshadows other problems. People might just focus on the suicide attempt and forget to address other issues that were going on beforehand, when what they really need to do is make sure that the person gets the appropriate treatment for all of the problems they may have."