Predisposing and Precipitating Factors for Suicide Among Alcoholics: Empirical Review and Conceptual Integration

Impulsive-aggressive traits and suicidal adolescents and young adults with alcoholism

Suicidal behavior and alcohol use disorders among adolescents and young adults are serious public health problems. In the study of suicidal behavior among young people with alcoholism, it has been shown that aggression and impulsivity are higher among those who attempted suicide. Impulsivity has been related to suicidal and self-destructive behaviors within different psychiatric conditions, i.e. alcohol and substance use disorders, mood disorders, conduct disorder, impulse control disorders, antisocial personality disorder, and borderline personality disorder. The term impulsivity has been used to define different constructs such as (1) personality trait or cognitive style in which disinhibition is the core characteristic, (2) a tendency to act immediately in response to external or internal stimuli, and (3) a group of psychiatric disorders with behavioral dyscontrol. Among adolescents suicidal behavior is transmitted in families independently of psychiatric conditions, but not independently of impulsivity/aggression. Two causal links between impulsiveness and alcoholism have been proposed: (1) adolescents who develop alcoholism possess higher premorbid levels of impulsiveness than those who do not develop alcoholism, and (2) levels of impulsiveness differentiate both populations only after the development of alcoholism, with higher levels of impulsiveness among those adolescents who developed alcoholism. Cognitive behavioral techniques have shown promising results in the treatment of adolescents with alcohol and substance use disorder and suicidality. The relative frequency of suicidal behavior among adolescents and young adults suffering from alcoholism and its subsequent devastating effects on individuals, families and society merits further research and development of prevention strategies.

THE ASSOCIATION BETWEEN ALCOHOL MISUSE AND SUICIDAL BEHAVIOUR

AIMS

Despite recent small reductions in overall suicide rates, rates among those aged 25-44 have remained high. The aim of this paper was to examine the evidence for a link between alcohol misuse/consumption and suicidal behaviour, explore the reasons for this association, and consider the implications for reducing rates of suicidal behaviour.

METHODS

A medline search was performed to find relevant research evidence.

RESULTS

There is evidence to suggest alcohol misuse predisposes to suicidal behaviour through its depressogenic effects and promotion of adverse life events, and both behaviours may share a common genetic predisposition. Acute alcohol use can also precipitate suicidal behaviours through induction of negative affect and impairment of problem-solving skills, as well as aggravation of impulsive personality traits, possibly through effects on serotonergic neurotransmission.

CONCLUSIONS

Effective interventions for problem drinking may help reduce suicide rates. At a public health level, reducing overall alcohol consumption may be beneficial, and the measures shown to be most effective in this regard are those that aim to restrict availability of alcohol.

The black-white suicide paradox: possible effects of misclassification

This research addresses the paradox that the crude and age-adjusted suicide rates of United States blacks are less than half those of whites despite similar risks. Upper and lower limits for true suicide rates are estimated to assess the potential for differential suicide misclassification by race. Construction of these two rate scenarios respectively incorporate one or all of the three cause-of-death categories identified in the literature as most prone to obscure suicides: injury of undetermined intent and unintentional poisonings and drownings. The data source is the US Centers for Disease Control and Prevention's Web-based Injury Statistics Query and Reporting System, and the observation period is 1999-2002. We found that as in the official rates, the racial suicide gap persists within the lower and upper limit scenarios. However, there is marked shrinkage under the upper limit scenario. That scenario even generates rate crossovers for males ages 45-54 years and females ages 85 years and older. Suicide data appear relatively more deficient for black females than for black males. Racial data disparities are minimal for youth and young adults, and maximal for middle-aged males and the oldest and younger middle-aged females. Results strongly indicate greater susceptibility of medico-legal authorities to misclassify black suicides than white suicides. To demystify the racial suicide paradox, research is needed on medical histories and other biographical information that are accessible by the authorities in equivocal cases. To meet the standards of evidence-based medicine and public health, high-quality suicide data are an imperative for risk group delineation; risk factor identification; policy formulation; program planning, implementation, and evaluation; and ultimately, effective prevention.

Suicidal Behavior in Alcohol-Dependent Subjects: The Role of Personality Disorders

BACKGROUND

Comobidity of personality disorders (PDs) and alcohol dependence are considered to increase the risk for suicidal behavior. The aim of this study is to assess the influence of Diagnostic and Statistical Manual of Mental Disorder-fourth edition (DSM-IV) personality characteristics and comorbid axis I disorders on suicidal behavior in alcohol-dependent inpatients.

METHODS

Characteristics of alcohol dependence and suicidal behavior were obtained using the Semi-Structured Assessment on Genetics in Alcoholism (SSAGA). Personality disorder characteristics were assessed using the Structured Clinical Interview for DSM-IV Axis II Disorders.

RESULTS

Three-hundred seventy-six treatment-seeking alcohol-dependent subjects, of whom 55% were diagnosed to have a PD and approximately 25% had a history of at least 1 suicide attempt, were enrolled into the study. Subjects with PDs in all clusters reported a higher rate of suicide attempt history, depression episodes, and depression during the most serious attempt. As indicated by univariate and multivarate analysis, this pattern of suicide attempt characteristics was most pronounced in borderline disordered subjects and alcoholic individuals who live alone.

CONCLUSION

Subjects with alcohol dependence who have various comorbid PDs and depression deserve special attention in psychiatric care to prevent suicide. Psychotherapeutic strategies may have to be adapted to treat this high-risk population.

The relationship between the frequency of alcohol use and suicide rates in young people

BACKGROUND

Suicide is an important public health problem and one of the leading causes of death among adolescents. In the United States, the death rate from suicide amongst 15-19 year olds doubled between 1960 and 2001. It has been suggested that alcohol misuse contributed to this increase in suicide rates among young people. We examined the relationship between the percentage of frequently drinking high school students and suicide rates among 15-24 year olds in 17 countries.

METHODS

Correlations were computed to examine the relationship between suicide rates in 15-24 year old males and females and the percentage of frequently drinking students in 17 countries. Using median split, countries were divided into two groups according to the percentage of frequently drinking students. Suicide rates in countries with the lower percentage of frequently drinking students were compared to suicide rates in countries with the higher percentage of frequently drinking students using t-test.

RESULTS

There was a negative correlation between the percentage of frequently drinking students and suicide rates in both males (n=17, r = -0.51, p = 0.037) and females (n=17, r = -0.55, p = 0.023). The countries with the lower percentage of frequently drinking students had higher suicide rates in both 15-24 year old males (t = 2.25, df=15, p = 0.005) and females (t = 4.03, n=15, p = 0.001).

CONCLUSION

Suicide rates among 15-24 year old males and females were lower in the countries with the higher percentage of frequently drinking high school students. Our finding is consistent with the suggestion that "alcoholism tends to protect one against suicide early on, but after 20-25 years (if not earlier) it exacerbates suicide potential" (Maris, 1992). The results of this study should be treated with caution until replicated.

Serum Lipids and Risk Factors for Attempted Suicide in Patients with Alcohol Dependence

BACKGROUND

Alcohol dependence is a major risk factor for suicidal behavior. Although a number of risk factors have been suggested there is still no well-defined risk profile for attempted suicide in alcoholic patients. Alterations of serum lipids have been associated with completed as well as attempted suicide and with suicidal ideation. This study investigated potential demographic and clinical risk factors for attempted suicide in alcohol-dependent patients taking serum lipids additionally into consideration.

METHODS

One-hundred ten alcohol-dependent patients who were admitted to a psychiatric university hospital department for inpatient treatment were grouped according to whether or not they had a lifetime history of attempted suicide. Attempters versus nonattempters as well as attempters who used a violent versus a nonviolent suicide method were compared.

RESULTS

Patients who had attempted suicide at least once in their life differed significantly from those who had no history of suicide attempts. Univariate analyses showed that they were younger (41.7 years vs 46.8 years; p = 0.003), were more often smokers (97% vs 77%; p = 0.011), had more frequently coabused benzodiazepines (54% vs 17%; p = 0.002), and scored currently higher on the Montgomery and Asberg Depression Rating Scale (MADRS) global scale (26.3 vs 20.2; p = 0.005) as well as the "suicidal thoughts" item (1.8 vs 0.6; p = 0.001). Additionally, they had higher serum triglyceride levels (178.9 vs 127.5; p = 0.039). A logistic regression analysis left coabuse of benzodiazepines [odds ratio (OR), 5.26; p = 0.001], younger age (OR per year increase of age, 0.91; p = 0.006), and current MADRS item 10 ("suicidal thoughts") score (OR per point increase in MADRS item 10 score, 1.43; p = 0.019) as significant factors. Suicide attempters who had used a violent method were significantly more often male (82% vs 44%; p = 0.035), were younger (38.2% vs 45.1 years; p = 0.008), and had less frequently coabused tranquilizers (35% vs 78%; p = 0.018) than nonviolent attempters.

CONCLUSIONS

These findings contribute to the development of a more specific profile of alcohol-dependent individuals at risk for suicidal behavior. Further research is required to determine the role of serum triglycerides for suicidal behavior in patients with alcohol dependence.

Personality traits as correlates of suicidal ideation, suicide attempts, and suicide completions: a systematic review

OBJECTIVE

Involvement of personality traits in susceptibility to suicidality has been the subject of research since the 1950s. Because of the diversity of conceptual and methodological approaches, the extent of their independent contribution has been difficult to establish. Here, we review conceptual background and empirical evidence investigating roles of traits in suicidal behaviors.

METHOD

We selected original studies published in English in MEDLINE and PsycINFO databases, focusing on suicidal ideation, suicide attempts, or suicide completions, and using standardized personality measures.

RESULTS

Most studies focused on investigating risk for suicide attempts. Hopelessness, neuroticism, and extroversion hold the most promise in relation to risk screening across all three suicidal behaviors. More research is needed regarding aggression, impulsivity, anger, irritability, hostility, and anxiety.

CONCLUSION

Selected personality traits may be useful markers of suicide risk. Future research needs to establish their contributions in relation to environmental and genetic variation in different gender, age, and ethnocultural groups.

Prevalence of major depressive disorder in Nigerian college students with alcohol-related problems

OBJECTIVES

The study aimed to estimate the prevalence of major depressive disorder (MDD) among Nigerian college students with alcohol-related problems (ARP) and compare the estimated prevalence with their counterparts without ARP.

METHOD

A cross-sectional survey of a representative sample of students (n=2658) in six colleges in Osun state, Western Nigeria. The students were independently assessed for ARP and MDD with the Mini International Neuropsychiatric Interview (MINI).

RESULTS

The current (2 weeks) prevalence of MDD in college students with alcohol dependence is 23.8%; alcohol abuse 17.2% and hazardous use 12.4%. Compared with total abstainers, major depressive disorder is significantly more likely to be associated with diagnosis of alcohol dependence (OR 3.14, 95% CI 1.42-6.96), alcohol abuse (OR 2.27, 95% CI 1.38-3.72) and hazardous use (OR 1.64, 95% CI 1.12-2.38), but less associated with alcohol users without ARP (OR 0.93, 95% CI 0.69-1.25).

CONCLUSION

Nigerian college students with ARP are significantly more at risk of depressive disorders than those without ARP. Early recognition and treatment of depression are important considerations when planning preventive strategies for alcohol-related problems in college students.

Alcoholism and suicidal behavior: a clinical overview

OBJECTIVE

The purpose of this paper was to provide a clinical review of the literature on the relation of alcoholism to suicidal behavior.

METHOD

Studies of alcoholism and suicidal behavior available in MEDLINE, Institute for Scientific Information Databases (Science Citation Index Expanded, Social Sciences Citation Index, and Arts & Humanities Citation Index), EMBASE, and Cochrane Library were identified and reviewed.

RESULTS

Alcoholism is associated with a considerable risk of suicidal behavior. Individuals with alcoholism who attempt or complete suicide are characterized by major depressive episodes, stressful life events, particularly interpersonal difficulties, poor social support, living alone, high aggression/impulsivity, negative affect, hopelessness, severe alcoholism, comorbid substance, especially cocaine abuse, serious medical illness, suicidal communication, and prior suicidal behavior. Partner-relationship disruptions are strongly associated with suicidal behavior in individuals with alcoholism.

CONCLUSION

All individuals with alcoholism should receive a suicide risk assessment based on known risk factors.

Alcohol consumption and suicide

About 90% of people in Western countries use alcohol at some time in their lives, and 40% experience temporary or permanent alcohol-related impairment in some area of life as a result of drinking. Multiple sociocultural and environmental factors influence suicide rates, and thus studies conducted in one nation are not always applicable to other nations. Impulsivity and aggression are strongly implicated in suicidal behaviour. Constructs related to aggression and impulsivity confer additional risk for suicidal behaviour in people with alcohol dependence. Lower serotonin activity is tied to increased aggression/impulsivity, which in turn may enhance the probability of suicidal behaviour. Acute alcohol use is associated with suicide. Suicide completers have high rates of positive blood alcohol. Intoxicated people are more likely to attempt suicide using more lethal methods. Alcohol may be important in suicides among individuals with no previous psychiatric history. Alcohol dependence is an important risk factor for suicidal behaviour. Mood disorder is a more powerful risk factor for suicide among problem drinkers as age increases. All individuals with alcohol use disorders should be assessed for suicide, especially at the end of a binge or in the very early phase of withdrawal. Middle-age and older men with alcohol dependence and mood disorders are at particularly high risk.

Psychotherapy in the treatment of alcohol and substance abusing adolescents with suicidal behavior

Adolescence is a unique time period in an individual's life, one in which suicide and substance abuse become substantial health risks. Currently, suicide accounts for approximately 14% of all deaths among 15-24 year olds in the U.S.A. Drug, alcohol abuse and dependence are the most prevalent causes of adolescent morbidity and mortality in the USA. Numerous studies have demonstrated the link between adolescent alcohol, substance abuse and suicide. When compared to community controls, the rate of a substance abuse disorder was 8.5 times higher in a sample of adolescent suicide completers and the rate of alcohol abuse was 7.5 times higher. Genetic and biological variables may also be responsible for either alcohol and substance abuse or suicide or both alcohol and substance abuse and suicide. There is little empirical research evaluating the effectiveness of alcohol and substance abuse treatments for adolescents. Therapies such as multisystemic therapy, functional family therapy, motivational interviewing, community reinforcement, the 12-step approach and contingency management reinforcement seem to be effective treatments. Despite the strong association between adolescent alcohol and substance use and suicidal behaviors, few studies have investigated the combined treatment of these two issues. Cognitive behavioral therapy, particularly dialectical behavior therapy, seems to be a promising psychotherapy treatment for suicidality in alcohol and substance abusing adolescents. Further research is needed to determine the efficacy of various treatments of alcohol and substance abusing adolescents with suicidal behavior.

Personality traits as intermediary phenotypes in suicidal behavior: genetic issues

A genetic contribution to the risk of suicidal behavior is now supported by many studies. It probably involves specific factors acting on their own, independently of the genetic transmission of associated psychiatric disorders. A history of childhood maltreatment, adverse events, psychosocial stress, psychological traits and major psychiatric disorders all appear to contribute to the global risk of suicide attempt or completion. The interplay between previously identified risk factors, different as they are in nature and degree of complexity, still remains to be clarified. A stress-diathesis model has been proposed, where trait-like genetic and developmental risk factors (the diathesis) interact through still unknown mechanisms with actual (stress-related) factors to create the conditions for a suicidal gesture. Disentangling the effects of these risk factors, and specifically the effects of the genetic factors influencing these different pathological conditions, appears to be a difficult task. Indeed the results of candidate gene association studies suggest that genetic vulnerability factors for various related psychiatric phenotypes (major psychiatric disorders and personality traits) partly overlap with more specific factors predisposing to suicidal behavior. Personality traits are partly under genetic control and may be closer to the genetic effects than psychiatric syndromes. We review here the available data on the genetics of personality traits presumably involved in suicidal behavior, focusing on the association studies carried out with serotonin-related genes. We suggest that future studies on the genetic vulnerability to suicidal behavior should include the investigation of endophenotypes, with the aim of deciphering the mechanisms underlying the genetic susceptibility to these closely associated phenotypes.

Alcohol use and suicide rates

Alcohol use and abuse substantially influence suicide rates. Suicide is a cause of death for a substantial percentage of individuals with alcoholism. However, the results of epidemiological studies of the relation between alcohol use and suicide have been inconsistent. Studies conducted in one nation are not always applicable to other nations. Many different factors including prevalence of various psychiatric and medical disorders, quality of psychiatric and medical care, unemployment and divorce rates and other psychosocial and demographic factors determine suicide rates in a certain region or a country. There may be a broad-based social characteristic related to social stress which is associated with high rates of a variety of stress-related behaviors, including heavy alcohol use and suicide.