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Suicide among US military veterans is an epidemic. More veterans have taken their own lives this century than died in all of our armed conflicts. We know that there are several factors that increase the risk of veteran suicide. And we often take it on faith that if we successfully deal with those factors that the risk of suicide will go down. One of the major risks for suicide is substance abuse. One of the treatment approaches for substance abuse is to put the patient into treatment either inpatient or outpatient. The question is, do substance abuse treatment programs reduce suicide risk and which ones work better?

Inpatient vs Outpatient Substance Abuse Programs and Suicide Risk

A study of 3733 veterans with substance abuse issues looked at inpatient versus outpatient programs. One the things they took note of was the incidence of suicide attempts. They recorded attempts in the twelve months prior to treatment, during treatment, and the twelve months after treatment. The average length of treatment in this cohort was twelve months. What they found was those veterans who were in residential treatment had a lower rate of suicide attempts during treatment than those who partook of outpatient programs. That relationship held even when the baseline degree of suicide risk as adjusted for.

The study did not find a difference between inpatient and outpatient treatment when it came to suicide attempts after a person finished their treatment program. What they did find was that the length of treatment made a difference. People who were in treatment longer, either inpatient or outpatient, had fewer suicide attempts than those who had shorter periods of treatment. Also, availability of psychiatric services in substance abuse programs and any use of such services had no correlation with suicide attempt rates in either inpatient or outpatient settings.

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Treatment Programs Versus Psychotherapy Versus Medication for Substance Abuse

Substance abuse treatment programs are designed to get people to quit abusing drugs or alcohol. To the extent that they reduce the risk of suicide that is great. However, there are other approaches to reducing drug and alcohol abuse. These include psychotherapy with and without medications. Medicines that have been found to be effective include SSRI antidepressants and psychedelics. While there are excellent studies of psychedelics like MDMA and psilocybin for PTSD and depression respectively, there is little follow-up in regard to suicide risk.

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There has been research in regard to psychedelic use and suicide risk, however. Canadian researchers studied marginalized women in Vancouver. They choose women who had no prior suicide attempts. Because these marginalized women were living in awful circumstances it is not surprising that suicide ideation and attempts occurred. What the researchers found was that women who had used psychedelics at any time in their life had a 60% lower likelihood of suicidality than those who had never used psychedelics. This benefit did not include all types of drug use. Use of crystal methamphetamine ranked along with a history of childhood abuse as reasons for a much higher risk of suicidality.

Where Do Substance Abuse Patients Go After Therapy?

We know that social isolation, community and family issues and particularly loss of close relationships are all risk factors for suicide. Something that might seem counter intuitive is that married couples often break up after a person with substance abuse becomes sober and maintains sobriety. Thus, a person might be simply exchanging one risk factor for another in regard to suicide. While people are in treatment there are in a type of social setting, one that is more structured and directed than usual but a social setting. Once someone leaves that setting there may be a sense of loss even when treatment has otherwise been successful. Although individuals who follow up with 12 step programs like AA or NA can maintain something of that structured social setting, not everyone does. Thus it is not a total surprise that suicide risk appears to go up when patients leave a structured inpatient social setting.

In regard to veteran suicide it is clear that at least in the year after completing substance abuse treatment, more needs to be done to deal with suicide risk even in individuals that have successfully completed their therapy.

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