Shame, Alcoholism, Stigma, and Suicide

In addiction treatment circles, conventional wisdom suggests we have to let people hit rock bottom before we can help them. But what happens if rock bottom is dying from suicide?

Historical records as far back as ancient Athens have the underpinnings of the stigmatization of suicide. In 360 BCE, Plato wrote that those who died by suicide “shall be buried alone, and none shall be laid by their side; they shall be buried ingloriously in the borders of the twelve portions the land, in such places as are uncultivated and nameless, and no column or inscription shall mark the place of their interment.” Fast-forward a couple millennia and suicide is still criminalized in many places around the world. In the Western Judeo-Christian tradition, suicide has long been considered the ultimate sin, to such an extent that even the body of a person who died by suicide was legally brutalized and dehumanized. This long history of shaming and penalizing suicide has created deeply seated (mis)beliefs that are engrained in cultural norms. Suicidal ideation is stigmatized, and those who experience such thoughts often suffer in silence.

Alcoholism (both alcohol use disorder and alcohol dependence) is also highly stigmatized. Past research has found that public attitudes are very poor towards people with substance use disorders (SUD). Across the globe, around 70% of the public believe alcoholics were likely to be violent to others. As recently as 2014, research has found 30% of people think recovery from SUDs is impossible and almost 80% of people would not want to work alongside someone who had or has a substance use disorder.

Alcohol dependence and alcohol use disorder (AUD) are high on the list of risk factors for suicide. Mood disorders, such as depression, anxiety, and bipolar disorder, are even higher risk factors. What is particularly concerning is that mood disorders frequently go hand in hand with AUDs. Alcohol causes depression, and it can be hard to distinguish whether the alcohol or the depression came first because they feed each other. In his book Alcohol Explained, author William Porter explains, “hangovers cause depression whether you are mentally ill or not…the real cause of it is the chemical imbalance in the brain and body. ”

People who have alcohol dependence are 60 to 120 times more likely to attempt suicide than people who are not intoxicated and individuals who die as a result of a suicide often have high BAC levels. Alcoholism is positively correlated with an increased risk of suicide and “is a factor in about 30% of all completed suicides.” A 2015 meta-analysis on AUD and suicide found that, across the board, “AUD significantly increases the risk [of] suicidal ideation, suicide attempt, and completed suicide.”

Suicide attempts with self-inflicted gunshots have an 85% fatality rate. If someone does survive a suicide attempt, over 90 percent of the time they will not die from suicide. That margin of survival gets smaller with alcohol dependence. Being intoxicated increases the likelihood that someone will attempt suicide and use more lethal methods, such as a firearm.

When a suicide attempt survivor encounters medical professionals, half of the time they will be interacting with someone who has “unfavorable attitudes towards patients presenting with self-harm.” (These statistics have cultural and regional variations.) When a patient with AUD encounters medical professionals, they are also likely to be met with negative perceptions. Myths about AUD and alcohol dependency are pervasive and not even nurses are immune to such prejudice.

So what improves professional perceptions and treatment outcomes? Education. Training works to dispel myths and reinforce the fact that SUDs are diagnosable conditions that require as much care and attention as any other potentially fatal ailment. Perhaps increased understanding of these conditions and experiences could fuel progress for treating addictions and preventing suicide. Doctors are sometimes at a loss for what to do with alcoholic patients; interestingly, the physicians who had more confidence in their abilities in this area were associated with worse outcomes. Meanwhile, there has been little progress in treatment availability outside of basic peer support groups such as Alcoholics Anonymous.

Peer support groups do help a lot of people get and stay sober and to live happier and healthier lives: 12-step proponents credit the steps and meetings for saving their lives; many say they were suicidal and that after getting sober they no longer had those thoughts. But while suicidal ideation may go away for some people who receive treatment, it doesn’t work like that for everyone.

People who are abstinent from drugs and alcohol still die from suicide. In the case of post-traumatic stress disorder, quitting drinking can exacerbate feelings of hopelessness and despair. Continuing to drink may reduce the severity of the symptoms in the very short term, but ultimately “a diagnosis of co-occurring PTSD and alcohol use disorder [is] more detrimental than a diagnosis of PTSD or alcohol use disorder alone.”

Suicide is a leading cause of death across the world and ranks as the 10th most common cause of death in the United States. For every completed suicide, there are an estimated 25 attempts.

It’s clear that we must do something to reduce the number of lives lost by suicide. Raising awareness of the relationship between alcohol-dependence and suicide attempts is an important part of the equation. Medical professionals, social workers, law enforcement, employers, and others who are frequently the first point of contact need better training to improve attitudes and fine tune skill sets for taking appropriate action. The public also needs to be armed with information that they can use to help their family and friends who may be at risk for suicide, and in particular what to do if that person has a co-occurring SUD.

Despite evidence to the contrary (particularly in the case of comorbidity with another mental illness) conventional wisdom in addiction treatment suggests that we have to let people fall to rock bottom before we can help them. But what happens if rock bottom is dying from suicide? It’s true that we can’t force health onto another person, but we also can’t help them if they’re no longer alive. For many people, prior trauma and mental health issues come before addiction. More evidence-based intervention and prevention programs are needed if we hope to make any headway in fighting this epidemic.

Until that happens, opportunities do exist to help prevent suicide. After Logic released his Grammy winning song titled “1-800-273-8255” (the phone number for the National Suicide Prevention Lifeline), calls to the Lifeline increased exponentially. There is nothing quite like hearing another human voice offering support and comfort. There is also a growing number of online crisis support services which provide help through live chat and email. These, unlike many crisis phone numbers, are not limited by location. Texting a crisis hotline such as the US Crisis Text Line at 741741 is also an option and can be done with just basic SMS, no data needed.

If you or someone you know is in immediate danger, call your local emergency number. Find your country’s equivalent to 911 on this wiki page or through The Lifeline Foundation. Find a list of additional suicide prevention resources worldwide on this page.

Originally published on The Fix.