The Suicide Spectrum

Suicide is a leading cause of death in the US, reported the Centers for Disease and Prevention (CDC) in 2018. “Suicide rates increased in nearly every state from 1999 through 2016. Mental health conditions are often seen as the cause of suicide, but suicide is rarely caused by any single factor,” stated the CDC report.

In their presentation as part of the Williamsburg Place Lecture Series, behavioral health specialists Omoroniké Hamilton and Angele Moss-Baker stressed the fact that suicide has “permeated our society” in the last few years. In the mental health field, suicide is “an expectation,” said Hamilton, who is the clinical director of Aquila Recovery. Moss-Baker is the owner of Comprehensive Addiction & Psychological Services. Both are well-known trainers and consultants.

Precise statistics on suicides are difficult to obtain. The CDC points out “many people who die by suicide are not known to have a diagnosed mental health condition at the time of death.” The lack of diagnosis does not necessarily mean absence of a mental health problem. At the same time, it is not always easy to determine whether a self-inflicted death was intentional or unintentional. Many drug overdose deaths are deemed to be unintentional as it remains unclear whether the intention of users was to kill themselves.


Suicide as a Spectrum

The two-fold objective of the presentation was to be able to differentiate between intentional and unintentional deaths by utilizing a four-quadrant model for assessing suicide risk. Hamilton and Moss-Baker also advocate a more fluid interpretation of suicidal intention. They assess the risk of suicide on a spectrum that integrates co-occurring behavioral health issues such as trauma, depression, and substance use disorder (SUD).   

This would allow therapists to go beyond asking “Have you been having thoughts about killing yourself?” and explore a wider array or risk factors such as family history, availability of firearms in the home, depression, traumatic experiences, and substance misuse. Sexual orientation, gender identity and ethnicity can also be relevant. As Moss-Baker points out, 12 percent of youth suicides are people with an LGBTQ background. They are often bullied, and  many are homeless. They experience “cumulative trauma” and are thus at a higher risk of developing an SUD or committing suicide.

The distinction between deliberate and accidental self-poisoning is particularly murkey in the realm of severe substance use disorders. During their lecture, Hamilton and Moss-Baker highlighted a sample of celebrity deaths inviting the audience to opine on which ones were accidental and which ones were intentional. There were no easy answers as most cases featured dangerous substance misuse and co-occurring mental health problems, creating a complicated spectrum of risk factors that ended in lethal self-harm.

To counter this spectrum, Hamilton and Moss-Baker advocated an evidence-based and more integrated approach to treatment. They pointed out that “historically, addiction counselors viewed suicide as a mental health issue, and at the same time, mental health professionals were not always trained to work with suicidal persons who had co-occurring mental and substance use problems.” This silo mentality needs to change. “Working collaboratively across the mental health and substance use fields is key to reducing suicide rates and overdoses.”

Hamilton and Moss-Baker briefly introduced the Minkoff four-quadrant model that assesses the severity of both mental health and substance use disorders while providing a basic framework for matching disorder severity with appropriate treatment. If both co-occurring disorders are severe the most intensive care setting is required.

Hamilton and Moss-Baker then combined the Minkoff quadrants with the Joiner suicide risk assessment. The widely-used Joiner assessment looks at three factors, desire, capability, and intent. If all three factors are present and protective buffers are absent, the suicide risk is considered high.


The Mossilton


The Mossilton Four Quadrents

If you combine the Minkoff quadrants with the Joiner suicide risk assessment you get what the presenters have semi-seriously dubbed the “Mossilton” (Moss-Baker/Hamilton). It can provide a four quadrant fully-integrated suicide assessment that looks at mental illness (MI), substance use disorder (SUD), and suicide risk.

Hamilton and Moss-Baker pointed out that “more than 142,000 Americans died from drug or alcohol overdoses and from suicide in 2016, an 11 percent increase over 2015.” They hope  a more integrated approach to treatment of all three health problems will turn this tide of despair in the future.