Many people are not aware that approximately half of suicides are not associated with depression. Suicide can occur in the context of an anxiety disorder, personality disorder, psychotic illnesses, or as an impulsive response to an adverse life event (133). Suicide is not an inevitable consequence of any of these conditions, including depression. Most people rescued from potentially lethal suicide attempts do not ultimately commit suicide. That is why barriers on bridges and other devices to prevent impulsive suicides are necessary.
Alcohol and substance abuse are major causes of morbidity and mortality (134). The essential feature of substance dependence, or addiction, is the continued use of the substance despite serious resulting problems. Alcohol and substance abuse are among the most common—and most frequently overlooked—conditions in medical practice.
In the DSM-IV-TR, the term “substance” can mean a medication, a toxin, or a drug of abuse.
Nicotine is included among “substances,” and women appear to be more susceptible to nicotine addiction than men, but smoking cessation is more a topic for general medicine than for psychiatry (9,135).
Substance abuse leads to major complications, including intoxication and withdrawal.
Withdrawal is major problem because, as mentioned in this chapter in the section on benzodiazepines, patients often fail to inform clinicians of their alcohol and substance use before being hospitalized or undergoing procedures, when they may experience unanticipated undiagnosed withdrawal (136–138).
Significant problems caused by continued use of the substance may include symptoms of withdrawal, interference with family and work obligations, and the depletion of, or criminal activity to obtain, resources to obtain the substance. Other features include tolerance, or the need to consume more of the substance to obtain the same effect, and compulsive use (139).
Patients frequently use alcohol along with other substances of abuse. The abuse of prescription medication, especially in younger populations, has increased (140). Patients should be advised to take care that their medications are not accessible to others.
Alcohol is the most frequent substance of abuse. Legal and accepted by society, it nevertheless causes a high proportion of morbidity, mortality, and life complications. Women’s alcohol abuse is more likely to take place in private than is men’s; society frowns more on women who are drunk or create disturbances in public than on men who do the same. Women are more likely than men to use a substance because an intimate partner uses or abuses that substance, and to trade sexual favors for access to the substance (141). There is strong evidence for a genetic link for alcoholism, but not for the other substances of abuse.
The most successful treatment for substance abuse disorders is a so-called 12-step program such as Alcoholics Anonymous. Most of the programs for the treatment of substance abuse were developed for men. Women are less responsive to the usual confrontational approach (142,143). Many women with substance abuse issues have children. Such women, and women who are pregnant, are often reluctant to enter treatment for fear of prosecution or losing custody.
Treatment programs for women with primary responsibility for children must include arrangements for child care. Recidivism after treatment is very common, but that does not mean that treatment is useless. On average, patients require three episodes of treatment before achieving sobriety (139). The essential obligation of the primary physician is to ask each patient about substance consumption and any problems arising from it (141). Buprenorphine is a useful adjunct medication; physicians are required to undergo specific training in order to prescribe buprenorphine (144).
Anxiety is a sense of dread without objective cause for fear, accompanied by the usual physical concomitants of fear. Although every human being has anxious feelings from time to time, anxiety disorders are diagnosed when anxiety becomes disabling or so painful as to interfere with an individual’s quality of life. Anxiety disorders place patients at risk for suicide (145).