Mental Health, Substance Misuse, And Suicide: Shared Risk And .

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June 2018Mental Health, Substance Misuse, andSuicide: Shared Risk and Protective FactorsIntroductionThe onset of mental illness typically occurs inMental health, substance misuse, and suicide areadolescence through early adulthood, with 50%major public health issues [1–3]. Separately, andtogether, they contribute to high direct and indirect of lifetime mental illness cases beginning by agecosts to individuals, families, and society as a whole 14 and 75% occurring by the age of 24 [11]. Young[4–6]. Further, evidence suggests that these issues adults (18-25) had the highest rates of AMI (22.1%)often co-occur and can havea synergistic and/or additiverelationship [7]. For example,Summary Boxover 50% of individuals with a Substance misuse, mental illness, and suicide are major public healthsubstance use disorder haveissues that often co-occur in additive or synergistic relationships. Certain populations, including adolescents, LGBT populations,a co-occurring mental illnessand some racial and ethnic minorities are at an increased risk toand 90% of children who diedexperience substance misuse, mental illness, and suicide.by suicide also had a mental Shared risk factors for substance use/misuse, mental illness,health condition [8,9]. In lightand suicide include: adverse childhood events; lack of parentalof this fact, it is important tosupervision; and a family history of mental illness, substance use,understand the shared risk andsuicidal behavior, and bullying.protective factors of these is Shared protective factors include: strong familial, peer, andsues and explore interventionscommunity connections; early detection and treatment of mentalthat can effectively address riskillness and/or substance use; and access to evidence-based mentalfactors and promote protectivehealth and substance use prevention and treatment services.factors. Potential strategies to address the shared risk factors and promoteMental Health / Illnessprotective factors associated with mental illness, substance misuse,and suicide include: investing in public education campaigns toreduce stigma, developing strategies to increase early and regularmental health/substance use screenings, and improving access toeffective and affordable treatment.Almost 45 million U.S. adultssuffer from a mental illness[10]. The term mental illnessencompasses many differentconditions, which fall under twooverarching categories: any mental illness (AMI)and serious mental illness (SMI). AMI includes allrecognized mental health diagnoses, where SMI is asubset of conditions characterized by more severesymptoms and outcomes [10].CENTER FOR HEALTH POLICYand SMI (5.9%), followed by adults ages 26-49(21.1% and 5.3%), and those 50 and older (14.5%)[10].18-H05

June 2018Rates of mental illness are higher among womenand individuals reporting more than one race[10]. Additionally, certain groups of people aredisproportionately affected by mental illness,including homeless populations; those that identifyas lesbian, gay, bisexual, or transgender (LGBT); andthose that are incarcerated [12–14].the highest rates of tobacco and illicit drug usecompared to other racial and ethnic groups [15,17].Co-occurring Disorder (Dual Diagnosis)Substance use disorders and mental illness oftenoccur at the same time; this is referred to as a cooccurring disorder or dual diagnosis. Almost 40%,or 7.9 million, of U.S. adults with a past-year SUD alsoSubstance Usehad AMI in the past year and 2.3 million individualsSubstance use refers to the use of alcohol, with a past-year SUD experienced an SMI [9].tobacco, and illicit drugs or the non-medical use of Approximately 30% of adolescents with a past-yearprescription pharmaceuticals. This can occur in a SUD experienced a co-occurring major depressivemanner or amount that causes harm to the user or episode in the past year [9]. Rates of co-occurringto those around them.disorders are highest among individuals between 18 Alcohol is the most commonly used and misused and 25 years of age (29.3%) [9].substance in the nation. More than half of all U.S.residents ages 12 and older used alcohol in the It is often difficult to accurately assess whetherpast month and nearly one-fourth engaged in the SUD or mental illness presented first, and it isbinge drinking (National Survey on Drug Use and important to note that there is not necessarily acausal relationship between SUD and mental illnessHealth [NSDUH], 2016). Tobacco is the next most commonly used [18]. However, evidence suggest that there are somesubstance, with 17% of adults reporting current common pathways to the development of a cocigarette smoking (Behavioral Risk Factor occurring disorder: 1) abuse and misuse of drugsSurveillance System [BRFSS], 2016). Tobacco use can lead to individuals experiencing symptoms ofremains the leading cause of preventable death mental illness; 2) those experiencing a mental illnessand disease in the U.S., resulting in approximately may begin self-medicating with legal and/or illegalsubstances; and 3) there may be overlapping risk480,000 deaths each year [15]. Approximately 27.8 million Americans or 10.4% factors that predispose individuals to developing coof the U.S. population ages 12 and older used an occurring disorders [18,19].illicit substance in the past month; this includesthe misuse of prescription pain relievers (NSDUH,2016). Overall, nearly 20.5 million U.S. residentsexperienced a substance use disorder (SUD) inthe past year and 19 million needed but did notreceive treatment for their SUD (NSDUH, 2016).There are differences in drug use prevalence acrossdemographic groups in the U.S. For example, menare more likely to report heavy alcohol use, tobaccouse, and illicit drug dependence than women[15,17]. American Indians and Alaskan Natives hadCENTER FOR HEALTH POLICY218-H05

June 2018SuicideRates of suicide (death that results from a selfinflicted, intentional act) and suicidal behavior (actsor thoughts of self-harm with the intent of causingdeath) have been increasing in recent years [20–22].Suicide is the 10th leading cause of death overall andthe second leading cause of death in adolescentsages 15 to 19 in the U.S. [23,24]. Additionally, it isestimated that 1.4 million individuals in the U.S.made a suicide attempt and 10 million had thoughtabout committing suicide in 2015 [2]. Death fromShared Risk and Protective FactorsEvidence suggests that there are many sharedrisk and protective factors associated with thedevelopment of mental health conditions, substanceuse and misuse, and suicide and suicidal behavior[28–31]. This section provides a description of theshared risk and protective factors for mental illness,substance misuse, and suicide (see Figure 1).Evidence has shown that mental illness, substanceuse, and suicide and suicidal behavior often co-Figure 1. Shared Risk and Protective Factors DiagramSubstance UseDisorders Riskand ProtectiveFactorsShared RiskandProtectiveFactorsMental IllnessRisk andProtectiveFactorsSource: SAMHSA [28]suicide is more common in males, particularly whitemales; however, women are more likely to attemptsuicide. Rates of suicide are highest in individualsbetween 45 and 64 years of age (19.6%), followedby those 85 and older [23]. Additionally, LGBTpopulations and current and former members of themilitary also have a higher likelihood of attemptingand completing suicide [25,26]. Firearms, used in alittle over half of all deaths by suicide, are the mostcommon method, followed by suffocation (25.9%),and poisoning (14.9%) [27].occur [7,30]. Substance abuse and mental illnesshave both been found to be associated with higherrates of suicide and suicidal attempts [32–35].Mental health issues have also been found to bean underlying risk factor for the development of asubstance use disorder, and conversely, substanceuse is sometimes cited as an associated risk factorfor mental health issues [36–39]. Further, evidencesuggests that these issues often have a synergisticor additive influence on each other [38].CENTER FOR HEALTH POLICY3

June 2018Adverse childhood events have also been cited asrisk factors for mental illness, substance use, andsuicide. These adverse events can range from mental,physical, and sexual abuse, to other traumas, suchas a sudden loss [36,40].treatment of mental illness and/or substance use,particularly during adolescence, is an importantfactor in reducing lifetime incidence of these issues[43].Indiana EpidemiologyOther studies have looked at social environments, Data about rates of substance misuse, mentalincluding family and peer relationships, as common illness, and suicide in Indiana were obtained from therisk factors for these conditions [39,41]. Lack of National Survey on Drug Use and Health (NSDUH),parental supervision is a cited riskYouth Risk Behavior Surveyfactor for both substance use and(YRBS), and CDC WONDER datamental illness [41]. Additionally,on suicide.family history or mental illness,substance use, and/or suicidalPrevalence of Mental Illnessbehavior have also been linked to anFigures 2 and 3 present data on theincreased likelihood of developingpercentage of individuals in Indianaan SUD, mental illness, or suicidalwith any mental illness (AMI)behavior [36].and those with a serious mentalillness (SMI). Indiana’s ratesAnother risk factor that has emergedare compared to national rates.is bullying, including direct personIndiana fares slightly worse thanto-person and cyberbullying [42]. Additionally, the rest of the country for these key mental healthstudies assessing shared risk factors often focus on indicators. Twenty percent of persons 18 and over inspecific populations, such as adolescents [43], since Indiana had AMI, compared to 18.1% for the entireadolescence is a crucial period in the development U.S. population. Rates of AMI were highest amongof mental illness and substance use and subsequent young adults ages 18-25 years. The percentage ofsuicide behavior. LGBT populations have also adults with an SMI in the past year in Indiana wasreceived significant attention as these populations almost 5% compared to 4% for the rest of the U.S.have disproportionately high rates of mental illness, Rates of AMI and SMI in Indiana were highest amongsubstance use and misuse, and suicidal behavior young adults ages 18-25 years.[31,44,45].In addition, to identifying the common risk factorsassociated with these conditions, studies have alsoattempted to identify common protective factorsthat can assist in reducing resultant morbidity andmortality. Studies suggest that strong familial, peer,and community connections form an importantprotective factor for the prevention of mentalillness, SUD, or suicidal behavior [36,43]. Accessto evidence-based mental health and substanceuse prevention and treatment services [43] is alsoan important protective factor. Early detection andCENTER FOR HEALTH POLICY418-H05

June 2018Figure 2. Percentage of Adults with Any Mental Illness in the Past Year(Annual Averages Based on 2015 and 2016 NSDUH)353025Percent2015105018 18 to 2526 Indiana20.024.919.1U.S.18.121.917.4Source: SAMHSA [46]Figure 3. Percentage of Adults with Serious Mental Illness in the PastYear (Annual Averages Based on 2015 and 2016 NSDUH)10Percent8642018 18 to 2526 Indiana4.96.54.7U.S.4.15.53.9Source: SAMHSA [46]CENTER FOR HEALTH POLICY5

June 2018Prevalence of SuicideFigures 8-10 provide data on suicideand suicidal behavior in Indianaas compared to the U.S. averages.Figure 8 presents the percentageof individuals that had a seriousthought of suicide in the past year,by age. Among adults 18 and older inFigure 4. Percentage of Population Ages 12 and Older Who Engaged in Binge Drinking in the Past Month (Annual AveragesBased on 2015 and 2016 NSDUH)50Percent40302010012 12 to 1718 to 2526 18 ource: SAMHSA [46]Figure 5. Percentage of Population Ages 12 and Older Who UsedIllicit Drugs in the Past Month (Annual Averages Based on 2015and 2016 NSDUH)302520PercentPrevalence of Substance UseFigures 4 through 7 present data onthe current status of binge alcoholuse, illicit drug use, tobacco use,and SUD. With the exception oftobacco, the average percentage ofbinge alcohol use, illicit drug use,and substance use disorder wereslightly lower than the nationalaverage. Approximately one in fouradults, ages 18 and over, reportedpast-month binge alcohol use.Past-month binge alcohol use washighest among individuals between18 and 25. A little over 8% of adults(18 and over) reported past-monthillicit drug use, with the highestpercentage of illicit drug use alsooccurring among individuals 18-25years of age. Indiana has tobaccouse rates higher than the nationalaverage across all age groups, withalmost two-thirds of adults (18 andolder) reporting past-month useof any tobacco product. Similar toalcohol and illicit drug use, those18-25 had the highest percentageof past-month use. Lastly, 6.1% ofIndiana residents (18 and older) hada substance use disorder in the lastyear, slightly lower than the U.S. rateof 6.7%. Again, those 18-25 had thehighest percentage of a SUD in thepast year.15105012 12 to 1718 to 2518 26 rce: SAMHSA [46]CENTER FOR HEALTH POLICY618-H05

June 2018As is seen in Figure 9, the percentageof high school students (grades9-12) that have attempted suicidehas been increasing over time, with6.6% of Indiana students in 2003reporting an attempted suicide inthe past year, compared to almost10% in 2015.Lastly, Figure 10 shows the rate ofsuicide over time in Indiana and theU.S. The rate of suicide has beenincreasing, with rates in Indianabeing slightly higher than thenational average. Indiana’s suiciderate has increased from 12.3 per100,000 in 2007 to 15.4 in 2016.Figure 6. Percentage of Population Ages 12 and Older Who Useda Tobacco Product in the Past Month (Annual Averages Based on2015 and 2016 NSDUH)5040PercentIndiana, 4.6% had a serious thoughtof suicide in the past year, comparedto 4% of the U.S. population. Similarto the mental illness and substanceuse indicators, those between 18and 25 had the highest percentageof individuals with serious thoughtsof suicide.2010012 12 to 1718 to 2526 18 ource: SAMHSA [46]Figure 7. Percentage of Population Ages 12 and Older with a Substance Use Disorder in the Past Year (Annual Averages Based on2015 and 2016 NSDUH)20Opportunities for Prevention15PercentReduce stigma associated withmental illness, substance usedisorders, and suicideMental illness, substance usedisorders,andsuicidehavehistorically been associated withhigh levels of stigma. Stigma canmanifest as public stigma, structuralstigma, and/or self-stigma. Publicstigma includes the attitudes andperceptions of these conditionsamong the general public [49,50].Interventions focused on this level30105012 12 to 1718 to 2526 18 Indiana7.14.214.87.46.1U.S.7.64.615.27.96.7Source: SAMHSA [46]CENTER FOR HEALTH POLICY7

June 2018of stigma should include publiceducation campaigns designedto provide the general public withevidence-based facts about theunderlying causes of mental illness,SUD, and suicide and dispel idualssuffering from these conditions[49,50]. There is evidence tosuggest that these public educationcampaigns can be effective indecreasing stigma. For example, astudy assessing the effectiveness ofa public media campaign in Scotlandto address inaccurate portrayalof mental illness, found that thecampaign was associated with a 17%decrease in the belief that individualswith mental illness are dangerous[51].Figure 8. Percentage of Adults Who Had Serious Thoughts of Suicide in the Past Year (Annual Averages Based on 2015 and 2016NSDUH)Structural stigma occurs in thepublic and private institutions thatindividuals with mental illness andSUD encounter. Common examplesof institutions in which theseindividuals may experience thisstructural stigma include healthcarefacilities and criminal justice orcorrectionalsystems[49,50].Interventions to address this levelof stigma should be designed toprovide workforce with training andskills development that allows themto better address these conditionsin the context of their interactionswith individuals experiencing mentalillness or SUD [50]. For example,programs aimed at providingmedical students with trainingspecifically designed to reducestigma and improve understandingFigure 9. Percentage of High School Students Who AttemptedSuicide in the Past Year (YRBSS, 2003-2015)141210Percent8642018 18 to 2526 Indiana4.69.13.8U.S.4.08.63.3Source: SAMHSA 9.98.08.6Note: 2013 YRBSS data are not available for Indiana due to a lowresponse rate.Source: CDC [47]CENTER FOR HEALTH POLICY8201318-H05

June 2018of individuals with mental illnesshave been associated with improvedconfidence in the clinical skillsneeded to work with individuals withthese conditions [49].Figure 10. Annual Suicide Mortality Rate per 100,000 Population(CDC WONDER, 2007-2016)18.016.014.0Lastly, self-stigma, which resultswhen individuals internalize public12.0and structural stigma that they10.0encounter, can also have negative8.0consequences for individuals with6.0mental illness and SUD. Evidencesuggests that interventions to4.0address self-stigma, such 120122013201420152016Therapy (ACT) groups 4.415.4and behavioral therapy designed ease psychological flexibility)or skills training and vocationalSource: CDC [48]counseling programs, can reducefeelings of shame and levels ofinternalized stigma, while decreasing feelings of Increasing screening capacity can be accomplishedin two ways, either by hiring additional individuals withsocial isolation [49,52].appropriate training or training existing personnelEarly and regular mental health and substance use on how to screen effectively for these conditions[53]. This could be accomplished by raising state orscreeningsThere is strong evidence to suggest that adolescence local funding for schools to increase the number ofand young adulthood are particularly vulnerable mental health professionals in educational settingstimes in the development of mental illness and/or [54,55]. Evidence has shown that expanding mentalsubstance use and misuse [53]. In light of this, it is health services in schools can improve accessimportant to identify strategies to increase access to mental health and substance use services byto early and regular mental health and substance removing logistical barriers and decreasing stigmause screenings [53]. These strategies should focus around care [54].on increasing capacity for screening in specificsettings, such as schools and primary care, and A strategy that has been promoted as an effectiveamong specific high-risk populations, i.e. children in tool in increasing access to substance use screeningfoster care [53]. There are many effective screening and subsequent treatment is training primarytools available. It is important to educate and train care providers on conducting Screening, Briefindividuals working in these settings with high-risk Intervention, and Referral to Treatment (SBIRT) [56].populations on best practices on how to screen for The use of SBIRT in clinical settings has been shownto produce short-term health benefits for individualsthese complex conditions [53].[56]. Additionally, many national organizations,CENTER FOR HEALTH POLICY9

June 2018such as the American Academy of Pediatricians, theNational Association of Pediatric Nurse Practitioners,and emergency physicians’ groups, support andpromote the use of SBIRT and other screening toolsfor mental health and substance misuse [53].therapy and counseling, connections to socialsupport services, continuing care, and integratedcare to address potential co-occurring conditions[60]. Unfortunately, this comprehensive treatmentapproach is further hindered by a fragmented andundersized mental health workforce [61].The Zero Suicide Initiative also focuses on increasingcapacity of providers with a specific focus on Strategies to improve access to behavioral healthcarescreening for suicide risk among patients [57]. This should look at how we pay for these services. Theprogram takes a systems approach to close the Affordable Care Act included provisions that extendedgaps in screening for and connecting individuals the Mental Health Parity and Addiction Equity Act,at risk for suicide to treatment in healthcare requiring that these services be covered as part ofsystems. Additionally, it recognizes the importance essential benefits with an equal level of benefits toof engaging the broader community in supporting those for the treatment of physical health problemsefforts to reduce suicide rates [57]. The Zero Suicide [60]. It is important to examine how these servicesInitiative is based on the Henry Ford Health System’s are being covered by state insurance programs,(Michigan)Perfectsuch as Medicaid andDepression Care model,the Healthy Indiana tedand ensure that coveragebest practices in quality 4.6% had a serious thought of suicide fortheseservicesimprovementandincludes basedcaretreatment and removesthe U.S. population.to address depressionbarriers to access. Inand suicide risk amongaddition, providers asits clients. This initiativewell as consumers needsaw an 80%reduction in the suicide rate among its to be educated on what services are covered as partclients [57]. Promoting and implementing the Zero of these programs.Suicide Initiative in healthcare systems in Indianacould have a significant impact on the rates of Conclusionsuicide in our state.Mental illness, substance misuse, and suicide arecomplex conditions that have serious public healthImprove access to effective and affordable treatment implications. Evidence suggest that these conditionsMental illness and substance misuse are both often co-occur and share many of the same risk andcomplex conditions that require specialized, and protective factors. Additionally, certain populationsoften, ongoing care. Unfortunately, individuals with are at increased risk of developing these conditions,these conditions do not always have adequate access including adolescents, LGBT populations, and someto appropriate services [58,59]. One in five adults with racial and ethnic groups. Nationally and in Indiana,AMI in the U.S. do not receive needed treatment [59]. several factors, including stigma, an undersizedAdditionally, only 18.5% of individuals 12 and older mental health workforce, and limited treatmentwho needed treatment for a SUD received it [58]. options, inhibit the effective identification andEffective mental health and substance treatment treatment of these conditions. It is important toservices include a mixture of treatment options develop and invest in strategies to reduce stigmaand services including medication, behavioralCENTER FOR HEALTH POLICY1018-H05

June 2018and misconceptions, increase early and ongoingscreenings, and improve access to effectivetreatments in order to better address mental illness,substance misuse, and suicide in Indiana.References1. .2.3.4.5.6.7.8.9.10.11.12.13.14.15.Centers for Disease Control and Prevention. (2018). Data and Publications - Mental Health. Retrieved fromhttps://www.cdc.gov/mentalhealth/data publications/index.htmCenters for Disease Control and Prevention. (2017). Suicide: Consequences. Retrieved from sequences.htmlU.S. Department of Health and Human Services. (2016.) Facing addiction in America: The Surgeon General’sReport on Alcohol, Drugs, and Health. Retrieved from als-report.pdfInsel, T. R. (2008). Assessing the economic costs of serious mental illness. American Journal ofPsychiatry,165, 663–665.National Institute on Drug Abuse. (2017). Trends & Statistics. Retrieved from atisticsShepard,D. S., Gurewich, D., Lwin, A. K., Reed, Jr., G. A., & Silverman, M. M. (2016). Suicide and suicidal attempts in the United States: Costs and policy implications. Suicide and Life-Threatening Behavior, 46, 352–362.National Institute on Drug Abuse. (2018, February). Common physical and mental health comorbidities withsubstance use disorders. Retrieved from nt of Health and Human Services. (1999). The Surgeon General’s call to action to prevent suicide.Retrieved from ubstance Abuse and Mental Health Services Administration. (2015). Behavioral health trends in the UnitedStates: Results from the 2014 National Survey on Drug Use and Health. Retrieved from DUH-FRR1-2014/NSDUH-FRR1-2014.pdfNational Institute of Mental Health. (2017). Mental illness. Retrieved from illness.shtmlNational Alliance on Mental Illness. (2018). Mental health by the numbers. Retrieved from he-numbersNational Alliance on Mental Illness. (2018). LGBTQ. Retrieved from https://www.nami.org/find-support/LGBTQU.S. Department of Housing and Urban Development. (2010). 2010 annual homeless assessment report toCongress. Retrieved from 010HomelessAssessmentReport.pdfJames, D. J., Glaze, L. E., et al. (2006). Mental health problems of prison and jail inmates. US Department ofJustice, Office of Justice Programs, Bureau of Justice Statistics Washington, DC.Centers for Disease Control and Prevention. (2018). Smoking and tobacco use: Fast facts. Retrieved fromhttp://www.cdc.gov/tobacco/data statistics/fact sheets/fast facts/CENTER FOR HEALTH POLICY11

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Substance Use Substance use refers to the use of alcohol, tobacco, and illicit drugs or the non-medical use of prescription pharmaceuticals. This can occur in a manner or amount that causes harm to the user or to those around them. and 25 years of age (29.3%) [9]. Alcohol is the most commonly used and misused substance in the nation.

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