Predictors of Clergy's Ability to Fulfill a Suicide Prevention Gatekeeper Role.

Catholic, Jewish and Protestant clergy (n = 801) completed a survey to identify predictors of clergy's ability to fulfill a suicide gatekeeper role. Exploratory backward stepwise regression identified predictors of risk identification including suicide knowledge, religion, conducting suicide funerals, having an attitude that people have a right to die, age, and race. Predictors of ability to intervene include suicide knowledge, training, religion, right to die attitude, and ethnicity. Recommendations include more suicide training and clergy self-care.

Clergy referral of suicidal individuals: a qualitative study.

In a national study, 25% of help-seekers contacted clergy; suicidal behavior was one of the significant predictors for making contact. Clergy have been found to refer 10% of help-seekers to mental health providers. This qualitative study explored the referral practices of 15 northeastern Mainline and Evangelical Protestant clergy when contacted by suicidal individuals; all referred to mental health providers. Participants reported low confidence with risk identification and provided moving examples of pastoral care.

Clergy as Suicide Prevention Gatekeepers.

801 U.S. Catholic, Jewish and Protestant clergy reported on their suicide gatekeeping activities. Using vignettes, they identified suicide risk and selected interventions for three risk levels. Two-thirds of the sample who provide counseling reported at least one contact from a suicidal person per year. Clergy were significantly more concurrent with experts in identifying risk and selecting interventions with high risk but deviated more from the experts with low and medium risk. Most reported needing more training.

Overdose after detoxification: a prospective study.

OBJECTIVE: The aim of this study was to determine predictors of non-fatal overdose (OD) among a cohort of 470 adults after detoxification from heroin, cocaine or alcohol. METHODS: We examined factors associated with time to OD during 2 years after discharge from an urban detoxification unit in Boston, MA, USA using multivariable regression analyses. Separate analyses were performed for both the total sample and a subgroup with problem opioid use. RESULTS: Lifetime prevalence for any OD was 30.9% (145/470) in the total sample and 42.3% (85/201) in patients with opioid problems. During the 2-year follow-up, OD was estimated to occur in 16.9% of the total sample and 26.7% of the opioid problem subgroup, with new-onset (incidence) OD estimated at 5.7% and 11.0%, respectively. Factors associated with an increased hazard of OD in both samples included white race, more depressive symptoms, and prior OD regardless of intent. Prior suicidal ideation or attempt was not associated with future OD. CONCLUSIONS: Findings underscore both the high prevalence of non-fatal OD among detoxification patients especially opioid users, and the potency of prior OD as a risk factor for future OD. Depressive symptoms, a modifiable risk factor, may represent a potential intervention target to prevent OD, including some "unintentional" ODs.

Suicidal behavior, drug use and depressive symptoms after detoxification: a 2-year prospective study.

INTRODUCTION: Individuals with substance-related disorders are at increased risk for suicidal behavior. Identifying those at higher risk for suicide among this population is difficult and informed mainly on the basis of cross-sectional data. METHODS: We examined factors associated with drug-related suicidal behavior using multivariable regression analyses in a 2-year prospective study of 470 inpatients enrolled from an unlocked, detoxification unit. Suicidal behavior included suicidal ideation (SI) and suicide attempt (SA). RESULTS: Lifetime prevalence for SI was 28.5%, and for SA, 21.9%. During the 2-year follow-up, 19.9% of the sample endorsed suicidal ideation and 6.9% reported a suicide attempt. Correlates of lifetime suicidal behavior included younger age, female, Hispanic, greater depressive symptoms, past sexual abuse, and problem sedative or alcohol use. Factors associated with suicidal behavior at follow-up included past suicidal behavior, more depressive symptoms, and more frequent benzodiazepine and alcohol use. Cocaine and heroin use did not reach statistical significance. CONCLUSIONS: Suicidal behavior is common among individuals with substance-related disorders. Differences in "suicide potential" may exist between drug categories with CNS depressants increasing the risk. These findings highlight the importance of addressing the recurrent 'suicide risk' of patients with substance-related disorders and regular monitoring for changes in depressive symptoms and drug use. Based on the prevalence and severity of this problem, the role of universal suicide screening of individuals with substance-related disorders merits greater attention.

Brain alcohol detectability in human subjects with and without a paternal history of alcoholism.

OBJECTIVE: This study examined the putative effects of a paternal history of alcoholism on the apparent detectability of brain alcohol in human subjects. METHOD: Brain to blood ethanol ratios in two cohorts of men were determined, using proton magnetic resonance spectroscopic imaging in a brain voxel (2 x 2 x 2 cm) containing the putamen. The men were light drinkers with a positive (n = 8) or a negative (n = 8) paternal history of alcoholism and were given an alcohol dose of 0.8 g/kg body weight. RESULTS: In both groups, brain alcohol detectability was less than 100%. No significant difference (p = .37) was found in the brain/blood ethanol ratios of the two groups. However, subjective assessments of feeling the extreme effects of alcohol and the extent of intoxication ("how drunk") were highly correlated with a paternal history of alcoholism, with the paternal history negative group reporting significantly more intense feelings of intoxication. CONCLUSIONS: A review of existing literature evidence and data obtained in this study indicate that brain alcohol detectability via magnetic resonance spectroscopic imaging is less than 100%. There were no significant differences in brain alcohol detectability between paternal history positive and paternal history negative men. Differences in the Subjective High Assessment Scale ratings between the two groups, however, indicate the importance of a genetic influence on the subjective response to alcohol.

A procedure that differentiates unintentional from intentional overdose in opioid abusers.

OBJECTIVE: The purpose of this study is to develop a procedure for assessing unintentional overdose (OD) in opiate abusers that differentiates it from intentional OD, and provides reliable information about the incident. METHODS: A sample of 121 patients in a methadone maintenance program at an urban university hospital completed a baseline assessment. A total of 70 participants completed an identical assessment at least 14 days later. The ability of an OD item to differentiate unintentional OD from intentional OD was tested, as was the test-retest reliability of questions assessing symptoms and treatment of OD. RESULTS: The procedure is reliable and differentiated unintentional OD from intentional OD. Questions assessing symptoms of OD were endorsed in almost every unintentional OD incident, although reliability was affected by loss of consciousness. The reliability of questions assessing emergency treatment and Narcan administration was outstanding. CONCLUSIONS: Our procedure for assessing OD differentiates unintentional OD from intentional OD. The use of follow-up questions assessing acute treatment for OD is recommended. Items concerning symptoms of OD are not needed to confirm the presence of an OD, but may be used to clarify whether an event was an OD.

Non-fatal overdose in the 12 months following treatment for substance use disorders.

BACKGROUND: Overdose (OD) is a leading cause of mortality and morbidity for individuals with substance use disorders (SUDs), and there are limited prospective data on OD during the months following treatment for SUDs. METHODS: Variables associated with an OD in the 12 months after leaving an initial treatment episode were examined in an analysis of the Drug Abuse Treatment Outcomes Study (DATOS), a longitudinal naturalistic multisite study. Participants included 2966 patients with one or more SUDs. Non-fatal OD was ascertained by a positive response to "In the past 12 months, have you overdosed on drugs?" Multivariate logistic regression analyses were used to identify variables associated with OD. RESULTS: By 12 months, 93 (3.1%) participants reported one or more ODs. Variables associated with OD were lifetime history of OD, injection drug use (IDU), male sex, greater pain, and history of sexual abuse. CONCLUSIONS: OD-risk appears to be increased by IDU, lifetime OD, sexual abuse history, and pain. The latter finding is novel for a prospective report and requires further study.

Impact of Internet pharmacy regulation on opioid analgesic availability.

OBJECTIVE: Access to prescription opioid analgesics has made Internet pharmacies the object of increased regulatory scrutiny, but the effectiveness of regulatory changes in curtailing availability of opioid analgesics from online sources has been not assessed. As part of an ongoing investigation into the relationship between the Internet and substance abuse, we examined the availability of prescription opioid analgesics from online pharmacies. METHOD: From a pharmacy watch Web site, we constructed a data set of postings entered every 3 months beginning November 1, 2005, that were related to the purchase of prescription opioid analgesics. Trained examiners assessed whether the final post described accessibility of pain medications that was increasing or decreasing. RESULTS: We identified 45 threads related to the availability of opioid analgesics from Internet pharmacies. Of the 41 (91%) threads describing the declining availability of opioid analgesic agents from Internet pharmacies, 34 (82%) received posts on November 1, 2007. Despite the subjective nature of the research question, there was high interobserver agreement between coders (kappa= .845) that availability of opioid analgesics from online pharmacies had decreased. This finding was supported by a dramatic rise in the number of pageviews (an accepted measure of Web site visitor interest in a page's content) of Web pages describing decreased availability of opioid analgesics. CONCLUSIONS: These data suggest striking decreases in the availability of prescription opioid analgesic pharmaceuticals. This self-reported change in drug availability may be related to increased regulation of and law enforcement operations directed against Internet pharmacies.

Transitions to, and correlates of, suicidal ideation, plans, and unplanned and planned suicide attempts among 3,729 men and women with alcohol dependence.

OBJECTIVE: Using a heuristic model of suicidal ideation and behavior, the two objectives were to identify correlates of (1) unique suicide-related outcomes (ideation, planning, planned attempt, unplanned attempt) and (2) specific transitions from one suicide-related category to the next. METHOD: Analyses were conducted with data from the Collaborative Study on the Genetics of Alcoholism (COGA), a six-site family pedigree study of individuals in treatment for alcoholism, their relatives, and control families. There were 3,729 subjects in the analysis; all were age 18 years or older with a diagnosis of current alcohol dependence according to the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised. Lifetime suicidal ideation, planning, and attempts were analyzed retrospectively. Correlates of each lifetime transition were analyzed using a series of multivariate logistic regressions. Multivariate multinomial regression analysis was used to examine correlates of each lifetime outcome. RESULTS: Female gender is uniquely associated with transitions to unplanned and planned attempts. Independent depression and substance-induced depression are associated with transitions to ideation and planning, whereas alcohol-related aggression is correlated with transitions to unplanned attempts. Analyses of suicide-related outcomes show that women are at higher risk for unplanned and planned attempts. Substance use and impairment are related to suicidal plans and attempts but not ideation. Independent and substance-induced depressions are associated with each suicide-related outcome, whereas alcohol-related aggression is uniquely related to unplanned attempts. CONCLUSIONS: Data underscore the heterogeneity of suicidal ideation and behavior among alcoholics and indicate the need to make clear distinctions between types of suicidal ideation and behavior in research and prevention efforts.

Treatment-associated suicidal ideation and adverse effects in an open, multicenter trial of fluoxetine for major depressive episodes.

BACKGROUND: Some reports suggest that a subset of depressed patients may experience suicidality - that is increase or emergence of suicidal ideation (SI) or behavior--after initiation of an antidepressant. The time course and clinical correlates of this phenomenon have not been characterized in detail. METHOD: We conducted a secondary analysis of a multicenter, prospective, open, 12-week trial of fluoxetine 20 mg in outpatients with nonpsychotic major depressive episodes. Adverse effects and other clinical features associated with the emergence of suicidality, defined using item 3 of the Hamilton Depression Rating Scale, were examined using Cox regression models. RESULTS: Among 414 subjects without SI at baseline, 59 (14.3%) reported SI on at least 1 postbaseline visit. In a Cox regression, emergence of activation and worsening of depression severity were independently associated with emergence of SI, along with female gender, younger age and having thoughts that life was not worth living prior to treatment. Treatment response and remission were significantly less likely among subjects who developed SI. CONCLUSIONS: New SI was relatively common in this trial of fluoxetine and associated with the emergence of activation and overall symptomatic worsening. Whether prophylaxis against or aggressive treatment of adverse events can decrease emergence of SI merits further study.