Association of alcohol and drug use disorders and completed suicide: an empirical review of cohort studies

The risk of repeated suicidal presentations following residential treatment for substance use disorders: A recurrent event analysis using linked administrative data

BACKGROUND

Individuals seeking alcohol and other drug (AOD) treatment consistently experience higher rates of suicidal behaviours and death by suicide when compared to the general population. By linking residential AOD treatment data to administrative healthcare and death datasets, we aimed to examine suicide-related behaviours and identify risk and protective factors for these events following discharge from residential treatment.

METHODS

Participants included 1056 individuals aged 18-69 (M = 32.06, SD = 9.55, male = 696,65.9 %) admitted to three residential treatment facilities in Queensland, Australia from January 1, 2014 to December 31, 2016. Treatment data was linked to administrative hospital, emergency department (ED), mental health service, and Registry of Deaths data 2-years post-discharge. ICD-10 codes were used to identify and analyse suicide-related events.

RESULTS

Within 2-years post-discharge, 175 (16.6 %) individuals had a suicide-related event (n = 298 episodes). The highest proportion of episodes (11.1 %) occurred within 1-month of discharge. Higher risk of a recurrent suicide-related event was associated with receiving a Disability Support Pension (aHR = 1.69 (95%CI:1.10,2.59), two or more previous episodes of residential AOD treatment (aHR = 1.49 (95%CI:1.30,2.15). Completing residential treatment was associated with a lower risk of suicide-related events (aHR = 0.54 (95%CI:0.35,0.83).

LIMITATIONS

The amalgamation of suicidal ideation, attempts, and death into a single outcome oversimplifies their complex nature and interplay. The exclusive focus on one service provider limits generalisability, and data constraints and missingness preclude many analyses.

CONCLUSIONS

Understanding suicidal behaviours and critical risk periods following discharge from residential treatment is crucial for improving continuing care, developing effective suicide prevention, and implementing targeted interventions among this high-risk population.

Suicide risk among young people who use drugs in Hanoi, Vietnam: Prevalence and related factors

AIM

Adolescents and young adults are vulnerable to suicidality, especially those at high risk such as young people who use drugs (YPUD). This study aimed to assess the prevalence and related factors of suicide risk among this population.

METHODS

We conducted a descriptive, cross-sectional study on YPUD aged 16-24 in the community in Hanoi, Vietnam. Data on socio-demographic characteristics, drug use, and adverse childhood experiences were collected using face-to-face questionnaires by research assistants. YPUD were screened by psychiatrists for depression, psychotic symptoms, and suicide risk, using the MINI questionnaire.

RESULTS

Three hundred-seven YPUD (250 males, 57 females) participated in the study; of those, 86 (28.0%) were at risk of suicide. Gender (female), adverse childhood experiences, depression, and psychosis were relevant factors.

CONCLUSION

The prevalence of suicide risk among young people using drugs was high. Therefore, suicide risk should be screened and monitored in the clinical assessment of this population. In addition, the intervention efforts to detect and intervene in adverse events during childhood may be one way to prevent mental health and suicide in later life.

Improving assessment and management of suicide risk among people who inject drugs: A mixed methods study conducted at the Medically Supervised Injecting Centre, Sydney

INTRODUCTION

People who inject drugs are 13 times more likely to die by suicide than the general population. Guidelines for responding to risk in this population are limited. Harm reduction services attended by people who inject drugs require targeted strategies to address the complexities of suicide risk among this population.

METHODS

Co-design, engaging health professionals and people with lived experience informed the study. Mixed methods were used to understand the experience of managing suicide risk among clients attending the Medically Supervised Injecting Centre (MSIC) in Sydney. A survey was administered to assess staff confidence in managing risk. Focus groups were conducted with health professionals and MSIC clients to explore experiences of suicide management, response and opportunities for improvement.

RESULTS

Half (N = 17) the MSIC staff surveyed reported over 10 years' experience working with this population. Confidence in managing suicide risk was low. Three key themes emerged from focus groups (N = 17): (i) Autonomy and the need to involve clients in the assessment process; (ii) Trust between clients and health professionals, and transparency in decision-making; and (iii) System barriers, described by health professionals as inadequate referral pathways for clients in distress, and by clients as negative experiences of care, including involuntary admission and not receiving medication (e.g. methadone).

DISCUSSION AND CONCLUSIONS

Revised assessment guidelines and a tailored safety plan were developed. These resources are also suitable for other alcohol and other drug services. The challenge in managing suicide risk in harm reduction services is balancing duty of care with staff-client relationships and client engagement.

A dose-response meta-analysis on the relationship between average amount of alcohol consumed and death by suicide

BACKGROUND

To determine whether sub-clinical levels of drinking may contribute to suicide risk, and whether the risk differs by sex, we aimed to evaluate the relationship between average amount of alcohol consumed per day and death by suicide.

METHODS

A systematic literature search was performed in Embase, Medline, PsycINFO, PubMed, and Web of Science from database inception up to April 27, 2022. The search strategies incorporated a combination of medical subject headings and keywords for "alcohol use" and "suicide". One-stage dose-response meta-analyses using a restricted maximum likelihood random-effect estimator were conducted to explore the relationship between average alcohol volume consumed and suicide, by sex. Three different shapes of the dose-response relationship-linear (on the log-scale), quadratic, and restrictive cubic splines-were tested.

RESULTS

A total of eight studies were included (three studies for females (n=781,205), and eight studies for males (n=1,215,772)). A linear dose-response relationship between average alcohol volume consumed and the log-risk of suicide was identified for both males and females. For males and females, a relative risk (RR) of 1.11 (95% CI: 1.05, 1.18) and 1.64 (95% CI: 1.07, 2.51) for suicide when consuming an average of 10 g of pure alcohol per day compared to lifetime abstention, 1.38 (95% CI: 1.14, 1.66) and 4.39 (95% CI: 1.21, 15.88) for 30g/day, and 1.71 (95% CI: 1.25, 2.33) and 11.75 (95% CI: 1.38, 100.33) for 50g/day, respectively.

CONCLUSIONS

As consumption increases, the risk of suicide increases proportionally. The risk of suicide associated with average daily alcohol consumption may be elevated for females, compared with males. Albeit, more research is needed, particularly among females.

Culturally tailoring a secondary suicide prevention intervention for American Indian and Alaska Native people in substance use treatment

BACKGROUND

Substance use treatment programs are ideal places for suicide prevention interventions. People who misuse substances are at elevated risk for suicide compared to the general population. However, most treatment programs do not incorporate suicide prevention, and none have been adapted for American Indian and Alaska Native (AI/AN) people. Preventing Addiction Related Suicide (PARS) is a suicide prevention module developed for use with people in treatment for substance misuse. A previous study demonstrated increased suicide help-seeking among this population.

OBJECTIVE

Culturally adapt PARS for use with AI/AN communities.

METHODS

We conducted focus groups and interviews with stakeholders in three Tribal health systems. We elicited feedback on PARS content, structure, and implementation. Data were analyzed using constant comparison. Results were used to adapt PARS and member checking was used to refine it.

RESULTS

Participants unanimously endorsed using PARS in their health systems. Suggested adaptations included shortening the module, using community-specific information, removing jargon and stigmatizing language, and emphasizing cultural connectedness.

DISCUSSION

This community-based, qualitative study adapted the PARS module for use with AI/AN communities. Research is needed to evaluate the clinical effectiveness of the adapted module. If found effective, this would represent the first evidence-based suicide prevention intervention among AI/AN individuals in treatment for substance misuse.

Burden of drug use disorders in the United States from 1990 to 2021 and its projection until 2035: results from the GBD study

BACKGROUND

Drug use disorders (DUDs) have emerged as one of the most significant public health crises, exerting a substantial influence on both community health and socio-economic progress. The United States (US) also suffers a heavy burden, it is necessary to figure out the situation from multiple perspectives and take effective measures to deal with it. Therefore, using the data from the Global Burden of Diseases, Injuries, and Risk Factors (GBD) 2021, we evaluated this topic.

METHODS

Annual data on DUDs-related burden were collected from the GBD study 2021. We calculated the indicator of estimated annual percentage change (EAPC) to evaluate the changing trend of burden. The Bayesian model for age-period-cohort was introduced to forecast the burden.

RESULTS

In 2021, the number and age-standardized rate of prevalence were particularly prominent, with 12,146.95 thousand and 3821.43 per 100,000, respectively. Higher burden was also observed in males, 15-45 years old populations, and opioid use disorders subtype. From 1990 to 2021, the DUDs-related burden increased in the US and all states, especially in West Virginia; and the national death-related burden with the highest increase (EAPC = 7.96). Other significant inverse associations were seen between EAPC, age-standardized rates, and socio-demographic index (SDI). Moreover, in the next 14 years, the projected DUDs burden remains exigent.

CONCLUSIONS

The burden of DUDs in the US is heavy and has been enlarging. This study proposes that greater attention should be paid to the strategies in males, the younger population, opioid use disorders, and low-SDI states implemented by decision-makers to achieve goals such as reducing burden.

Alcohol use disorder and risk of specific methods of suicide death in a national cohort

INTRODUCTION

Alcohol use disorder (AUD) is among the strongest correlates of suicide death, but it is unclear whether AUD status is differentially associated with risk of suicide by particular methods.

METHODS

The authors used competing risks models to evaluate the association between AUD status and risk of suicide by poisoning, suffocation, drowning, firearm, instruments, jumping, or other means in a large Swedish cohort born 1932-1995 (total N = 6,581,827; 48.8% female). Data were derived from Swedish national registers, including the Cause of Death Register and a range of medical registers.

RESULTS

After adjusting for sociodemographic factors and familial liability to suicidal behavior, AUD was positively associated with risk of suicide for each method evaluated (cumulative incidence differences: 0.006-1.040 for females, 0.046-0.680 for males), except the association with firearm suicide in females. AUD was most strongly associated with risk of suicide by poisoning. Sex differences in the effects of AUD and family liability were observed for some, but not all, methods. Furthermore, high familial liability for suicidal behavior exacerbated AUD's impact on risk for suicide by poisoning (both sexes) and suffocation and jumping (males only), while the inverse interaction was observed for firearm suicide (males only).

CONCLUSIONS

AUD increases risk of suicide by all methods examined and is particularly potent with respect to risk of suicide by poisoning. Differences in risk related to sex and familial liability to suicidal behavior underscore AUD's nuanced role in suicide risk. Future research should investigate targeted means restriction effectiveness among persons with AUD.

Recognition of adjustment disorder among patients with substance use disorders referred for suicide-related concerns in an academic hospital setting

BACKGROUND

Persons with substance use disorders (SUDs) have a greater risk of suicide compared with the general population. Adjustment Disorder (AD) has been under-researched in SUD populations.

OBJECTIVE(S)

To characterize rates, and associated features, of AD among persons with SUD for whom lethality concerns arise in a general hospital setting.

METHODS

Retrospective analysis of electronic medical record data from psychiatric consultations during a consecutive six-month period.

RESULTS

Compared with persons with SUD classified as non-attempters, suicide attempters were significantly more likely to be diagnosed with AD. Multiple logistic regression models revealed patients with SUD referred for suicide-related concerns have an increased risk of suicide attempt if also diagnosed with AD or if they have a history of prior suicide attempt.

CONCLUSIONS

These data are in line with the contention that SUD, with comorbid AD, portend significant risk for suicide. AD represents an important disorder to recognize and target in suicide prevention strategies.

Serotonin transporter knockdown relieves depression-like behavior and ethanol-induced CPP in mice after chronic social defeat stress

Patients with stress-triggered major depression disorders (MDD) can often seek comfort or temporary relief through alcohol consumption, as they may turn to it as a means of self-medication or coping with overwhelming emotions. The use of alcohol as a coping mechanism for stressful events can escalate, fostering a cycle where the temporary relief it provides from depression can deepen into alcohol dependence, exacerbating both conditions. Although, the specific mechanisms involved in stress-triggered alcohol dependence and MDD comorbidities are not well understood, a large body of literature suggests that the serotonin transporter (SERT) plays a critical role in these abnormalities. To further investigate this hypothesis, we used a lentiviral-mediated knockdown approach to examine the role of hippocampal SERT knockdown in social defeat stress-elicited depression like behavior and ethanol-induced place preference (CPP). The results showed that social defeat stress-pro depressant effects were reversed following SERT knockdown demonstrated by increased sucrose preference, shorter latency to feed in the novelty suppressed feeding test, and decreased immobility time in the tail suspension and forced swim tests. Moreover, and most importantly, social stress-induced ethanol-CPP acquisition and reinstatement were significantly reduced following hippocampal SERT knockdown using short hairpin RNA shRNA-expressing lentiviral vectors. Finally, we confirmed that SERT hippocampal mRNA expression correlated with measures of depression- and ethanol-related behaviors by Pearson's correlation analysis. Taken together, our data suggest that hippocampal serotoninergic system is involved in social stress-triggered mood disorders as well as in the acquisition and retrieval of ethanol contextual memory and that blockade of this transporter can decrease ethanol rewarding properties.

Suicidal thoughts and behaviors among untreated illicit substance users: a population-based study

OBJECTIVES

Research regarding the contribution of specific psychoactive substances to suicidality has yielded equivocal results. The present study examined the prevalence and factors associated with suicidal thoughts and behaviors among a population-based sample of untreated illicit substance users.

METHODS

A total of 616 illicit substance users who were recruited from high-risk areas of Shiraz using snowball sampling participated in the study. Eligible participants were individuals aged 18 years and older who regularly used one illicit psychoactive substance (e.g., opioids, heroin, cannabinoids, stimulants, hallucinogens) for at least one year and who had received no treatment for their drug use during the past year. Data were collected regarding socio-demographic characteristics, mental history, and substance use habits. Data regarding suicidal thoughts and behaviors were assessed using the Beck Suicidal Ideation Scale (BSIS) and self-reports of previous suicide attempts. Multiple logistic regression analysis was used to identify independent variables associated with suicidality.

RESULTS

Among the participants, 23.6% reported having had suicidal thoughts during the past week and 6.7% reported having attempted suicide during the past year. Methamphetamine was reported as the primary substance of use among approximately half of the participants who attempted suicide during past year (49.2%). Multiple logistic regression analysis showed that current suicidal thoughts were independently associated with having no job, a history of mental health condition, previous suicidal attempts, concurrent use of more than one substance, and using methamphetamine and heroin as the primary substances. Suicidal thoughts were not associated with increased odds of regular opium and cannabis use.

CONCLUSION

Both methamphetamine and heroin use are significantly associated with current suicidal thoughts. Evaluation of the risk of suicidality by physicians and mental health care professionals in both community and outpatient settings would be especially appropriate among those individuals using these psychoactive substances.

Experiential suicide prevention training for substance use treatment intensive outpatient program counselors: Stepped wedge cluster-randomized training study

INTRODUCTION

The goal of this study was to evaluate changes in knowledge, attitudes, and other key suicide prevention issues for substance use disorder (SUD) counselors trained to administer the Preventing Addiction Related Suicide (PARS) module as part of a large-scale clinical trial. PARS is a 3-hour, PowerPoint based intervention designed with and for community SUD agencies for their Intensive Outpatient (IOP) group therapy programs. A previous randomized study of 906 patients from 15 community SUD sites showed positive changes in patients' suicide prevention knowledge, attitudes, and help seeking.

METHODS

Counselor participants completed measures of knowledge and attitudes about suicide and their confidence treating suicidal patients at each step of a large, stepped wedge cluster randomized trial of PARS, including after the final step. Data analysis compared scores in steps prior to counselors' training in PARS with scores in the steps following counselors' PARS training.

RESULTS

A total of 126 counselors participated in the study (89 % of those approached; 89-92 % retention across follow-up). Evaluation of both PARS efficacy and the PARS training by SUD counselors was highly rated. Counselor scores after receiving PARS training (vs. scores prior to PARS training) showed greater suicide knowledge, less maladaptive attitudes about suicide, and greater confidence in working with suicidal patients.

CONCLUSIONS

Based on this rigorous test of PARS training for SUD counselors working in community SUD intensive outpatient programs, PARS training, as well as doing the PARS intervention, was rated as highly effective and acceptable. PARS offers an integrated, brief, engaging, and effective training method to improve suicide care for both SUD counselors and SUD clients.

Female Patients Show a Larger Reduction in Suicidal Ideation in Inpatient Addiction Treatment Than Male Patients: Results of a Single-Center Observational Study

Background

Substance use disorders (SUD) are prevalent disorders worldwide. Among other associated health problems, patients with SUD are at an increased risk of dying of suicide, with females displaying an even higher risk than males. Therefore, the aim of this study was to conduct a gender-sensitive evaluation of changes in suicidal ideation during multimodal inpatient treatment at a hospital facility specialized in treating addiction.

Methods

A total of 694 patients (68.2% male) completed routine assessment including suicidal ideation, abstinence confidence, impulsivity, emotion regulation, self-efficacy and autonomy and joy both before (T1) and at the end (T2) of treatment. Mean changes were evaluated with repeated measures MANOVAs.

Results

Before treatment, a total of n=127 (18.3%) of the respondents reported suicidal ideation, which was reduced to n=72 (10.4%) by the end of treatment. Among female patients, the change in reported suicidal ideation compared from T1 to T2 (21.7% vs 7.7%) was significantly higher than among male patients (T1: 16.7%%, T2: 11.6%; p=0.040). Generally, females reported worse symptoms scores and slightly higher numbers of suicidal thoughts at baseline (effect sizes ranging from η²=.008 - 0.044). While both genders significantly profited from the treatment, female patients generally showed larger improvements than male.

Discussion

Our study underscores the beneficial effect of addiction-specialized inpatient treatment on suicidal ideation. Additionally, we found a substantial gender effect: while female patients generally were more distressed before treatment, they also reported higher symptom reduction during the treatment. This result highlights the need to perform more gender-sensitive research and develop more gender-sensitive treatment programs.

Prenatal opioid use as a predictor of postpartum suicide attempts among reproductive-age women enrolled in Oregon Medicaid

BACKGROUND

The rates of suicide and opioid use disorder (OUD) among pregnant and postpartum women continue to increase. This research characterized OUD and suicide attempts among Medicaid-enrolled perinatal women and examined prenatal OUD diagnosis as a marker for postpartum suicide attempts.

METHODS

Data from Oregon birth certificates, Medicaid eligibility and claims files, and hospital discharge records were linked and analyzed. The sample included Oregon Medicaid women aged 15-44 who became pregnant and gave live births between January 2008 and January 2016 (N = 61,481). Key measures included indicators of suicide attempts (separately for any means and opioid poisoning) and OUD diagnosis, separately assessed during pregnancy and the one-year postpartum period. Probit regression was used to examine the overall relationship between prenatal OUD diagnosis and postpartum suicide attempts. A simultaneous equations model was employed to explore the link between prenatal OUD diagnosis and postpartum suicide attempts, mediated by postpartum OUD diagnosis.

RESULTS

Thirty-three prenatal suicide attempts by any means were identified. Postpartum suicide attempts were more frequent with 58 attempts, corresponding to a rate of 94.3 attempts per 100,000. Of these attempts, 79% (46 attempts) involved opioid poisoning. A total of 1,799 unique women (4.6% of the sample) were diagnosed with OUD either during pregnancy or one-year postpartum with 53% receiving the diagnosis postpartum. Postpartum suicide attempts by opioid poisoning increased from 55.5 per 100,000 in 2009 to 105.1 per 100,000 in 2016. The rate of prenatal OUD also almost doubled over the same period. Prenatal OUD diagnosis was associated with a 0.15%-point increase in the probability of suicide attempts by opioid poisoning within the first year postpartum. This increase reflects a three-fold increase compared to the rate for women without a prenatal OUD diagnosis. A prenatal OUD diagnosis was significantly associated with an elevated risk of postpartum suicide attempts by opioid poisoning via a postpartum OUD diagnosis.

CONCLUSIONS

The risk of suicide attempt by opioid poisoning is elevated for Medicaid-enrolled reproductive-age women during pregnancy and postpartum. Women diagnosed with prenatal OUD may face an increased risk of postpartum suicides attempts involving opioid poisoning.

Sex-Specific Association of Alcohol Use Disorder With Suicide Mortality: A Systematic Review and Meta-Analysis

Importance

Despite individual studies suggesting that sex differences exist in the association between alcohol use disorder (AUD) and suicide, most existing systematic reviews and meta-analyses have reported associations across the sexes.

Objective

To estimate the sex-specific association between AUD and suicide mortality.

Data Sources

Embase, MEDLINE (including MEDLINE In-Process), PsycINFO, PubMed, and Web of Science were searched from database inception to April 27, 2022.

Study Selection

Inclusion criteria consisted of the following: (1) original, quantitative study, (2) inclusion of a measure of association and its corresponding measure of variability (or sufficient data to calculate these [eg, 95% CI]), and (3) results stratified by sex.

Data Extraction and Synthesis

Data extraction was completed by one reviewer and then cross-checked by a second reviewer. Risk of bias was assessed by study design. Categorical random-effects meta-analyses were conducted to obtain sex-specific pooled estimates of the association between AUD and suicide mortality risk. Methodological moderators (ie, study design and comparator group) were assessed using sex-stratified meta-regressions.

Main Outcomes and Measures

The association between AUD and suicide mortality.

Results

A total of 16 347 unique records were identified in the systematic search; 24 studies were ultimately included for 37 870 699 participants (59.7% male and 40.3% female) (23 risk estimates for male and 17 for female participants). Participants ranged in age from 15 years to 65 years or older. Sex-specific meta-regression models indicated that study design (ie, longitudinal vs cross-sectional study design) affected the observed association between AUD and suicide mortality for both male participants (log odds ratio, 0.68 [95% CI, 0.08-1.28]; P = .03) and female participants (log odds ratio, 1.41 [95% CI, 0.57-2.24]; P < .001). For males and females, among longitudinal studies, the pooled odds ratios were 2.68 (95% CI, 1.86-3.87; I2 = 99% [n = 14]) and 2.39 (95% CI, 1.50-3.81; I2 = 90% [n = 11]), respectively.

Conclusions and Relevance

This systematic review and meta-analysis yielded substantive evidence that AUD was associated with suicide mortality and that the association was similar across the sexes. The findings underscore the importance of identifying and treating AUD as part of a comprehensive suicide prevention strategy.

Characteristics and co-morbidities associated with hospital discharges for opioid and methamphetamine co-use, United States 2016-2019

Introduction

The US overdose crisis is increasingly characterized by opioid and methamphetamine co-use. Hospitalization is an important opportunity to engage patients in substance use treatment. Understanding characteristics of co-use-related hospital stays can inform the development of services to better support this growing patient population.

Methods

We used 2016-2019 National Inpatient Sample data to conduct a cross sectional analysis of hospitalizations involving use of opioids, methamphetamine, or both. We used bivariate analysis to compare patient demographics. We then used multinomial logistic regressions to compare the proportion of hospital stays which indicated co-morbid diagnosis. To account for correlated data, we used generalized linear models to compare outcomes in hospital mortality, patient-directed discharge, and length of stay.

Results

Co-use-related stays had a higher proportion of co-morbid mental health (60.7%; 95% CI: 59.9-61.4%) and infectious diseases (41.5%; 95% CI: 40.8-42.2%), than opioid- or methamphetamine-related stays. Co-use-related stays increased between 2016 and 2019 and were associated with a higher proportion of patient directed discharge (10.7%; 95% CI: 10.4-11.0%) and longer length of stay (6.3 days; 95% CI: 6.2-6.4 days) compared to opioid (8.1%; 95% CI: 7.9-8.3% and 5.8 days; 95% CI: 5.8-5.9 days) and methamphetamine-related stays (6.5%; 95% CI: 6.3-6.6% and 5.5 days; 95% CI: 5.4-5.5 days).

Conclusion

Patients discharged with co-use differ from patients with opioid or methamphetamine use alone, representing a range of challenges and opportunities. In addition to offering treatment for both substance use disorders, hospital-based services that address co-occurring conditions may better support patients with co-use through targeted and tailored approaches.

Risk factors for deaths of despair in England: An ecological study of local authority mortality data

Deaths of Despair (DoD) are socially patterned fatalities encompassing those attributable to drug and alcohol misuse and suicide. DoD occur much more frequently in socially deprived communities. This ecological study aimed to yield new knowledge on the spatial distribution of DoD, and socioeconomic factors that predict DoD risk in England. Via ICD-10 coding, deaths nationally during 2019-2021 were classified to non-overlapping categories of drug-related death, alcohol-specific death, and suicide. The proportion of DoD from each of these causes was calculated and age standardised DoD rates were generated for local authorities. A multivariable regression model for DoD risk was developed using 25 socioeconomic indicators. In 2019-2021, an estimated 46,200 people lost their lives due to DoD. Rates were higher in the North and in coastal areas (p < 0.001), ranging regionally from 25.1/100,000 (SD 6.3) in London to 54.7/100,000 (SD 9.5) in the North East. Alcohol-specific deaths were the largest contributor of DoD, accounting for 44.1% (95%CI 43.5-44.8%) of all such deaths. Living in the North, unemployment, White British ethnicity, living alone, economic inactivity, employment in elementary occupations, and living in urban areas were significantly associated with elevated DoD risk. DoD in England are spatially patterned, with northern regions experiencing a much higher burden of mortality from these avoidable causes. This study provides novel insights into the area-level factors associated with DoD in England. Potential ecological error is a key limitation.

Suicide within 1 year of non-fatal overdose: Risk factors and risk reduction with medications for opioid use disorder

OBJECTIVE

Individuals with substance use disorders and overdoses have high risk of suicide death, but evidence is limited on the relationship between interventions following the initial overdose and subsequent suicide death.

METHODS

National Medicare data were used to identify Medicare disability beneficiaries (MDBs) with inpatient or emergency care for non-fatal opioid overdoses from 2008 to 2016. Data were linked with National Death Index (NDI) to obtain dates and causes of death for the sample. Cox proportional hazards models estimated the associations between exposure to interventions (mechanical ventilation, MOUD) and suicide death.

RESULTS

The sample (n = 81,654) had a suicide rate in the year following a non-fatal overdose of 566 per 100,000 person-years. Post-overdose MOUD was associated with an adjusted hazard ratio of 0.20 (95%CI: 0.05,0.85). Risk of suicide was elevated for those whose initial overdoses required mechanical ventilation as part of the treatment (aHR: 1.86, 95%CI:[1.48,2.34]).

CONCLUSIONS

The year following a non-fatal opioid overdose is a very high-risk period for suicide among MDBs. Those receiving MOUD had an 80% reduction in the hazards of suicide, while those whose overdose treatment involved mechanical ventilation had 86% higher hazards of death by suicide. Our findings highlight the importance of psychiatric intervention in this high-risk population. Efforts are needed to initiate and retain more patients in MOUD.

Trajectories of Service Contact before Suicide in People with Substance Use Disorders-A National Register Study

OBJECTIVE

This study aimed to identify trajectories of service use during the last year before suicide death and the characteristics associated with the trajectories in patients with substance use disorders.

METHODS

This study used a national registry data linkage, which included all patients with substance use disorders who died by suicide in Norway between 2010 and 2018. In- and outpatient contacts with mental health or substance use services during the last year before suicide death was analyzed by week using Sequence State Analysis and cluster analysis to identify trajectories. Logistic regression was used to measure the association between the characteristics and the trajectories.

RESULTS

We identified four trajectories of service contact. A brief contact trajectory (n = 366) with a low proportion of weeks in contact (M weeks = 8.3), associated with less psychosis or bipolar disorder (aOR = 0.13 (0.08-0.22)) and higher age. A regular contact trajectory (n = 160), with a higher proportion of contact (M weeks = 47.9), associated with psychosis or bipolar disorder (aOR = 3.66 (2.10-6.47)) and depressive or anxiety disorder (aOR = 3.11 (1.93-5.13)). An intermittent contact trajectory (n = 195) with most contacts with outpatient substance use disorder services (M weeks = 9.7). A continuous contact trajectory (n = 109) with a high proportion of inpatient contact (M weeks = 44.5), strongly associated with psychosis or bipolar disorder (aOR = 6.08 (3.26-11.80)).

CONCLUSION

Longitudinal descriptions of service use reveal different trajectories that are important to consider when developing policies or interventions to reduce the risk of suicide death in patients with substance use disorders.

Suicidal ideations and self-dehumanization in recently detoxified patients with severe alcohol use disorder: an experimental exploration through joint explicit-implicit measures

BACKGROUND

Metadehumanization (the feeling of being considered as less than human by others) is a pervasive phenomenon in psychiatric states, notably promoting self-dehumanization and suicide antecedents. However, its role in suicidal ideations among patients with addictive disorders remains unexplored. We thus investigated the involvement of metadehumanization/self-dehumanization in suicidal ideations and suicidal thoughts interference in severe alcohol use disorder.

METHODS

We measured metadehumanization, suicidal ideations, and desire for social contact through questionnaires among 35 recently detoxified patients with severe alcohol use disorder (26 males). We measured animalistic/mechanistic self-dehumanization using an Implicit Association Task, and suicidal thoughts interference using a Stroop Task with suicide-related words. We performed regression analyses while controlling for depression/anxiety.

RESULTS

Animalistic self-dehumanization was positively associated with suicidal thoughts interference and with decreased desire for social interactions, such link being absent for metadehumanization or mechanistic self-dehumanization.

CONCLUSIONS

This link between self-dehumanization and suicide-related factors suggests that a reduced sense of belonging to humanity is associated with self-harm antecedents. Results also emphasize the importance of using indirect measures to investigate sensitive variables, such as self-dehumanization and suicidal thoughts.

Suicides in National Hormone Pituitary Program Recipients of Cadaver-Derived Human Growth Hormone

Context

Numerous reports of suicide among individuals who received cadaver-derived human growth hormone (c-hGH) through the National Hormone Pituitary Program (NHPP) raised the alarm for potentially increased suicide risk.

Objective

We conducted a study to assess suicide risk in the NHPP cohort and identify contributing factors to facilitate early recognition and intervention.

Methods

The study population consisted of patients receiving NHPP c-hGH starting from 1957, and cohort deaths with an ICD code consistent with suicide or possible suicide through 2020 were evaluated. Descriptive data were extracted from medical records. Standardized mortality ratios (SMRs) to compare the observed number of suicide deaths in the cohort to the expected number were calculated using general population suicide rates by sex, age group, and time period.

Results

Among 6272 patients there were 1200 all-cause cohort deaths, of which 55 (52 male, 3 female) were attributed to suicide. Of these, 47 were identified by ICD code alone compared to an expected count of 37.8 (SMR = 1.25, 95% CI 0.91-1.66). Among male cohort members, the SMR was 1.33 (95% CI 0.97-1.78). Elevated risk of suicide was detected for cohort members aged 25-34 (SMR = 1.79, 95% CI 1.06-2.83) and during the period from September 19, 1985, to December 31, 1998 (SMR = 1.70, 95% CI 1.02-2.65).

Conclusion

Overall, the observed number of suicides among NHPP c-hGH recipients was not significantly higher than expected. However, certain subgroups may be at elevated risk of suicide. Studies are needed to better understand the nature and magnitude of suicide risk among c-hGH recipients to facilitate early intervention to prevent suicide deaths.

Factors associated with suicide in people who use drugs: a scoping review

BACKGROUND

Suicide is a significant contributor to global mortality. People who use drugs (PWUD) are at increased risk of death by suicide relative to the general population, but there is a lack of information on associated candidate factors for suicide in this group. The aim of this study was to provide a comprehensive overview of existing evidence on potential factors for death by suicide in PWUD.

METHODS

A scoping review was conducted according to the Arksey and O'Malley framework. Articles were identified using Medline, CINAHL, PsycINFO, SOCIndex, the Cochrane Database of Systematic Reviews and the Campbell Collaboration Database of Systematic Reviews; supplemented by grey literature, technical reports, and consultation with experts. No limitations were placed on study design. Publications in English from January 2000 to December 2021 were included. Two reviewers independently screened full-text publications for inclusion. Extracted data were collated using tables and accompanying narrative descriptive summaries. The review was reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines.

RESULTS

The initial search identified 12,389 individual publications, of which 53 met the inclusion criteria. The majority (87%) of included publications were primary research, with an uncontrolled, retrospective study design. The most common data sources were drug treatment databases or national death indexes. Eleven potential factors associated with death by suicide among PWUD were identified: sex; mental health conditions; periods of heightened vulnerability; age profile; use of stimulants, cannabis, or new psychoactive substances; specific medical conditions; lack of dual diagnosis service provision; homelessness; incarceration; intravenous drug use; and race or ethnicity. Opioids, followed by cannabis and stimulant drugs were the most prevalent drugs of use in PWUD who died by suicide. A large proportion of evidence was related to opioid use; therefore, more primary research on suicide and explicit risk factors is required.

CONCLUSIONS

The majority of studies exploring factors associated with death by suicide among PWUD involved descriptive epidemiological data, with limited in-depth analyses of explicit risk factors. To prevent suicide in PWUD, it is important to consider potential risk factors and type of drug use, and to tailor policies and practices accordingly.

Epidemiology and Clinical-Demographic Characteristics of Suicide Attempts in Alcohol Use Disorders in an Italian Population

Suicide is a leading cause of morbidity worldwide. Among the known risk factors, alcohol use disorders (AUDs) are particularly relevant, but data on the epidemiology and characteristics of suicide attempts (SA) in this group are lacking. We used electronic health records of national health services to identify individuals who received a diagnosis of AUD in the Metropolitan area of Bologna from 2009 to 2019. In this cohort we identified accesses to Emergency Departments for SA from 2009 to 2020. The Crude Suicide Rate (CSR) for 1,000 Person Years was 2.93, higher than the general population. The CSR was higher in females, within one year from receiving the diagnosis of AUD, in patients with psychiatric comorbidities, concomitant abuse of cannabis or benzodiazepines. As for Covid-19 pandemic, the risk ratio of SA was significantly higher in 2020 compared to 2019 in females. Our results are relevant to identify clinical risk factors for SA in patients with AUDs, which are strongly associated with suicide risk but with scarce data in the previous literature and paucity of evidence-based therapeutic interventions.

Suicide deaths and substance use in the Galician provinces between 2006 and 2020

Background

Suicide is a serious public health problem that affects our entire country, including the Galician provinces. The aim of this research was to study the variation in completed suicide rates, between 2006 and 2020, in the different Galician provinces and their relationship with the consumption of addictive substances.

Methods

Completed suicide data from the Spanish Office for National Statistics and the Institute of Legal Medicine of Galicia were analyzed with a Joinpoint regression model to determine time trends. The relationship between the variation in completed suicide rates with sociodemographic variables obtained from the Spanish Office for National Statistics and variables related to the consumption of substances obtained from the survey on alcohol and other drugs in Spain (EDADES) of the Government Delegation for the National Plan on Drugs was also analyzed.

Results

The Joinpoint regression model did not reveal any point of significant change in the period studied for any Galician province. The following variables correlated positively with the variation in completed suicide rates in the Galician provinces: masculinity ratio, average age, daily alcohol consumption and daily illegal substance consumption.

Conclusion

Applying preventive strategies on the daily consumption of alcohol and illegal substances would help reduce the rates of completed suicide in the Galician provinces.

Suicidal thoughts and behaviors in patients with chronic pain, with and without co-occurring opioid use disorder

BACKGROUND

Individuals with chronic pain and a co-occurring substance use disorder present higher risk of suicide, but the individual and joint impacts of chronic pain and substance use disorders on suicide risk are not well defined. The objective of this study was to exam the factors associated with suicidal thoughts and behaviors in a cohort of patients with chronic non-cancer pain (CNCP), with or without concomitant opioid use disorder (OUD).

DESIGN

Cross sectional cohort design.

SETTING

Primary care clinics, pain clinics, and substance abuse treatment facilities in Pennsylvania, Washington, and Utah.

SUBJECTS

In total, 609 adults with CNCP treated with long-term opioid therapy (>/= 6 months) who either developed an OUD (cases, n = 175) or displayed no evidence of OUD (controls, n = 434).

METHODS

The predicted outcome was elevated suicidal behavior in patients with CNCP as indicated by a Suicide Behavior Questionnaire-Revised (SBQ-R) score of 8 or above. The presence of CNCP and OUD were key predictors. Covariates included demographics, pain severity, psychiatric history, pain coping, social support, depression, pain catastrophizing and mental defeat.

RESULTS

Participants with CNCP and co-occurring OUD had an increased odds ratio of 3.44 in reporting elevated suicide scores as compared to participants with chronic pain only. Multivariable modeling revealed that mental defeat, pain catastrophizing, depression, and having chronic pain, and co-occurring OUD significantly increased the odds of elevated suicide scores.

CONCLUSIONS

Patients with CNCP and co-morbid OUD are associated with a 3-fold increase in risk of suicide.

Characteristics of single vs. multiple suicide attempters among adolescents: a systematic review and meta-analysis

There might be differential characteristics between those who have attempted suicide once in their lifetime (single attempters) and those who have attempted suicide two or more times (multiple attempters). We aimed to identify the factors that differentiate single and multiple attempters in child and adolescents. This study was conducted following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines, and the review protocol was registered in PROSPERO. We conducted a systematic literature search in three databases to identify original studies exploring the characteristics of single attempters vs. multiple attempters among adolescents. We considered a wide range for the definition of adolescent, following most recent recommendations: 10-24 years. We carried out a meta-analysis. Fourteen studies were included in the systematic review and 13 in the meta-analysis with a total sample of with a total of 4286 participants. The factors statistically significantly associated with being a multiple attempter in the meta-analysis were: anxiety disorders, depression severity, alcohol abuse, substance abuse, aggressiveness, and hopelessness. Multiple attempters have a more severe clinical profile, with greater severity of symptoms. Knowledge of the risk factors associated with being a multiple attempter could help us to predict which patients are more likely to reattempt suicide and need further monitoring and a tailored treatment. Prevention programs tailored for the adolescent population, along with identification of early risk factors, could help to prevent suicidal behavior among this vulnerable population.

Alcohol drinking in male patients with chronic schizophrenia: prevalence and its relationship to clinical symptoms

Background

It is common practice to associate schizophrenia (SCZ) patients with substance use. The most commonly used substances in China are tobacco and alcohol. However, few studies have focused on alcohol consumption itself in patients with SCZ. Thus the purpose of this study was to detect the prevalence of alcohol use and associated clinical factors in Chinese patients with SCZ.

Methods

A total of 616 male inpatients who met the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria for SCZ participated in this study. A detailed questionnaire, including data on alcohol consumption was used to collect demographic and clinical information on all patients. The five-factor model of the positive and negative syndrome scale (PANSS) was adopted to assess psychiatric symptoms.

Results

In this study, 31.49% of SCZ inpatients had a history of alcohol use, and 82.9% of these patients abstained from alcohol use after the onset of SCZ. Compared to nondrinkers, patients who drank were more likely to smoke (p = 0.004), more likely to have suicide attempts (p = 0.002) and suicidal ideation (p = 0.001), more severe positive (p < 0.001) and depressive symptoms (p = 0.034), but less severe negative symptoms (p = 0.04).

Conclusion

These findings suggest that alcohol use is common during the lifetime of SCZ patients and that alcohol use may be associated with clinical symptoms in SCZ patients.

Cross-phenotype relationship between opioid use disorder and suicide attempts: new evidence from polygenic association and Mendelian randomization analyses

Clinical epidemiological studies have found high co-occurrence between suicide attempts (SA) and opioid use disorder (OUD). However, the patterns of correlation and causation between them are still not clear due to psychiatric confounding. To investigate their cross-phenotype relationship, we utilized raw phenotypes and genotypes from >150,000 UK Biobank samples, and genome-wide association summary statistics from >600,000 individuals with European ancestry. Pairwise association and a potential bidirectional relationship between OUD and SA were evaluated with and without controlling for major psychiatric disease status (e.g., schizophrenia, major depressive disorder, and alcohol use disorder). Multiple statistical and genetics tools were used to perform epidemiological association, genetic correlation, polygenic risk score prediction, and Mendelian randomizations (MR) analyses. Strong associations between OUD and SA were observed at both the phenotypic level (overall samples [OR = 2.94, P = 1.59 ×10-14]; non-psychiatric subgroup [OR = 2.15, P = 1.07 ×10-3]) and the genetic level (genetic correlation rg = 0.38 and 0.5 with or without conditioning on psychiatric traits, respectively). Consistently, increasing polygenic susceptibility to SA is associated with increasing risk of OUD (OR = 1.08, false discovery rate [FDR] =1.71 ×10-3), and similarly, increasing polygenic susceptibility to OUD is associated with increasing risk of SA (OR = 1.09, FDR = 1.73 ×10-6). However, these polygenic associations were much attenuated after controlling for comorbid psychiatric diseases. A combination of MR analyses suggested a possible causal association from genetic liability for SA to OUD risk (2-sample univariable MR: OR = 1.14, P = 0.001; multivariable MR: OR = 1.08, P = 0.001). This study provided new genetic evidence to explain the observed OUD-SA comorbidity. Future prevention strategies for each phenotype needs to take into consideration of screening for the other one.

Suicidal behavior across a broad range of psychiatric disorders

Suicide is a leading cause of death worldwide. In 2020, some 12.2 million Americans seriously contemplated suicide, 3.2 million planned suicide attempts, and 1.2 million attempted suicide. Traditionally, the approach to treating suicidal behavior (SB) has been to treat the "underlying" psychiatric disorder. However, the number of diagnoses associated with SB is considerable. We could find no studies describing the range of disorders reported to be comorbid with SB. This narrative review summarizes literature documenting the occurrence of SB across the lifespan and the full range of psychiatric diagnoses, not only BPD and those that comprise MDE, It also describes the relevance of these observations to clinical practice, research, and nosology. The literature searches contained the terms "suicid*" and each individual psychiatric diagnosis and identified 587 studies. We did not include case reports, case series, studies only addressing suicidal ideation or non-suicidal self-injury (NSSI), studies on self-harm, not distinguishing between SB and NSSI and studies that did not include any individuals that met criteria for a specific DSM-5 diagnosis (n = 366). We found that SB (suicide and/or suicide attempt) was reported to be associated with 72 out of 145 diagnoses, although data quality varied. Thus, SB is not exclusively germane to Major Depressive Episode (MDE) and Borderline Personality Disorder (BPD), the only conditions for which it is a diagnostic criterion. That SB co-occurs with so many diagnoses reinforces the need to assess current and past SB regardless of diagnosis, and supports the addition of charting codes to the DSM-5 to indicate current or past SB. It also comports with new data that specific genes are associated with SB independent of psychiatric diagnoses, and suggests that SB should be managed with specific suicide prevention interventions in addition to treatments indicated for co-occurring diagnoses. SB diagnostic codes would help researchers and clinicians document and measure SB's trajectory and response to treatment over time, and, ultimately, help develop secondary and tertiary prevention strategies. As a separate diagnosis, SB would preclude situations in which a potentially life-threatening behavior is not accounted for by a diagnosis, a problem that is particularly salient when no mental disorder is present, as is sometimes the case.

Suicide Risk among Patients with Substance Use Disorders, A Cross Sectional Study In Suez Canal Area Hospitals.. [DOI: 10.21203/rs.3.rs-3076857/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Background: Substance Use Disorders are serious health issues that have been linked to numerous clinical correlations and mental health comorbidities. One of the most important health dangers linked to substance addiction was suicide. The current study aims to investigate the phenomena using a bio-psycho-social framework. The aim was to investigate the risk of suicide in a sample of substance use disorders patients. A case control comparison was performed between 190 substance abusers versus 30 controls. Addiction Severity Index, Beck Suicidal Ideation Scale, Arab Religiosity Scale, Socioeconomic Status Scale, as well as multiple historical variables, have been investigated. Results: Suicidality was prevalent among alcohol and opioids abusers, poly substance abusers, those with a family history of suicide, and those with a history of a previous attempt. Having a positive family history of suicide could predict an 8.3 point rise in Beck Suicidal Ideation Scale score, while having any previous attempt of suicide could predict 9.04 point rise in Beck Suicidal Ideation Scale score. Suicidality scores correlated with Addiction Severity Index scores, and indirectly with socioeconomic status and Religiosity. Combinations of drugs with other mental illness showed a significant predictive effect on suicidality score. Conclusion: Suicidality is expected among substance abusers, and is affected by multiple bio-psycho-social variables.

Prevalence, incidence, deaths, and disability-adjusted life-years of drug use disorders for 204 countries and territories during the past 30 years

Drug use disorders are increasingly recognized as the main cause of public health issues worldwide. The current analysis aims to provide the most comprehensive, updated estimates of the burden from drug use disorders at global, regional, and national levels during the past three decades. Prevalence, incidence, deaths, and disability-adjusted life-years (DALYs) were estimated from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 by age and sex for drug use disorder as well as its four main categories (opioid use disorders, cocaine use disorders, amphetamine use disorders, and cannabis use disorders) in 204 countries and territories between 1990 and 2019. DisMod-MR 2.1, and Bayesian meta-regression were used to analyze prevalence and incidence, while the Cause of Death Ensemble model (CODEm) was used to estimate death of diseases. Globally, the burden of drug use disorders, as measured by the average annual percentage change (AAPC) of deaths and DALYs, continues to increase. The patterns by regions of DALYs due to drug use disorders varied significantly, and it is mainly in developed countries and concentrated among young people and males. Programs for drug use disorders management should be improved, particularly in opioid use disorders. Governments will face increasing demand for treatment and support services, and effective prevention as well as control strategies are required to reduce the burden from these causes.

Contextual factors associated with country-level suicide mortality in the Americas, 2000-2019: a cross-sectional ecological study

Background

The suicide mortality rate in the Region of the Americas has been increasing, while decreasing in all other World Health Organization regions; highlighting the urgent need for enhanced prevention efforts. Gaining a better understanding of population-level contextual factors associated with suicide may aid such efforts. We aimed to evaluate the contextual factors associated with country-level, sex-specific suicide mortality rates in the Region of the Americas for 2000-2019.

Methods

Annual sex-specific age-standardized suicide mortality estimates were obtained from the World Health Organization (WHO) Global Health Estimates database. To investigate the sex-specific suicide mortality rate trend over time in the region, we performed joinpoint regression analysis. We then applied a linear mixed model to estimate the effects of specific contextual factors on the suicide mortality rate across countries in the region over time. All potentially relevant contextual factors, obtained from the Global Burden of Disease Study 2019 covariates and The World Bank, were selected in a step-wise manner.

Findings

We found that the mean country-level suicide mortality rate among males in the region decreased as health expenditure per capita and the proportion of the country with a moderate population density increased; and increased as the death rate due to homicide, prevalence of intravenous drug use, risk-weighted prevalence of alcohol use, and unemployment rate increased. The mean country-level suicide mortality rate among females in the region decreased as the number of employed medical doctors per 10,000 population and the proportion of the country with a moderate population density increased; and increased when relative education inequality and unemployment rate increased.

Interpretation

Although there was some overlap, the contextual factors that significantly impacted the suicide mortality rate among males and females were largely different, which mirrors the current literature on individual-level risk factors for suicide. Taken together, our data supports that sex should be considered when adapting and testing suicide risk reduction interventions, and when developing national suicide prevention strategies.

Funding

This work received no funding.

Prevalence of suicidal ideations and suicide attempts in patients with tuberculosis: A systematic review and meta-analysis

OBJECTIVE

Suicide and suicidal behaviors are reported to be common in patients with Tuberculosis (TB). This systematic review and meta-analysis aimed to quantitively assess the prevalence of suicidality and identify the factors associated with suicidality in patients with TB.

METHODS

We searched databases PubMed, SCOPUS, Web of Science, PsycINFO, and Google Scholar for studies that reported the prevalence of suicide, suicidal ideations, or suicide attempts in patients with TB. We assessed the quality of studies with the Newcastle Ottawa scale. Random-effects models were used to calculate the pooled prevalence with 95% confidence intervals (CI).

RESULTS

Nine studies (8770 participants) were included. Pooled prevalence for current suicidal ideations within the last year was 8.5% [95% CI: 5.8%12.3%]. Pooled prevalence for current suicidal attempts within the last year was 3.1% [2.2%- 4.5%]. Suicide was reported in 0.92% of TB patients at the end of 2 years, whereas 2.2% to 8.4% of all TB deaths were reported due to suicide. Factors associated with suicidality were female gender, TB retreatment, comorbid HIV, presence of another chronic medical illness, psychological distress, and comorbid psychiatric illnesses.

CONCLUSION

The prevalence rates of suicidal ideation and attempts were higher in patients with TB than in the general population. Integrating mental health services with TB programs will help develop interventions for high-risk individuals. Prospero registration number: CRD42021281849.

Chronic pain conditions and risk of suicidal behavior: a 10-year longitudinal co-twin control study

BACKGROUND

Understanding the relationship between chronic pain conditions and suicidal behavior-suicide attempt, other intentional self-harm, and death by suicide-is imperative for suicide prevention efforts. Although chronic pain conditions are associated with suicidal behaviors, these associations might be attributed to unmeasured confounding or mediated via pain comorbidity.

METHODS

We linked a population-based Swedish twin study (N=17,148 twins) with 10 years of longitudinal, nationwide records of suicidal behavior from health and mortality registers through 2016. To investigate whether pain comorbidity versus specific pain conditions were more important for later suicidal behavior, we modeled a general factor of pain and two independent specific pain factors (measuring pain-related somatic symptoms and neck-shoulder pain, respectively) based on 9 self-reported chronic pain conditions. To examine whether the pain-suicidal behavior associations were attributable to familial confounding, we applied a co-twin control model.

RESULTS

Individuals scoring one standard deviation above the mean on the general pain factor had a 51% higher risk of experiencing suicidal behavior (odds ratio (OR), 1.51; 95% confidence interval (CI), 1.34-1.72). The specific factor of somatic pain was also associated with increased risk for suicidal behavior (OR, 1.80; 95% CI, 1.45-2.22]). However, after adjustment for familial confounding, the associations were greatly attenuated and not statistically significant within monozygotic twin pairs (general pain factor OR, 0.89; 95% CI, 0.59-1.33; somatic pain factor OR, 1.02; 95% CI, 0.49-2.11) CONCLUSION: Clinicians might benefit from measuring not only specific types of pain, but also pain comorbidity; however, treating pain might not necessarily reduce future suicidal behavior, as the associations appeared attributable to familial confounding.

Understanding opioid use within a Southwestern American Indian Reservation Community: A qualitative study

PURPOSE

Morbidity and mortality due to nonprescription use of opioids has been well documented following the significant increase in the availability of prescription opioids in the early 2000s. The aim of this paper is to explore community beliefs about correlates of opioid risk, protective factors, and behavioral functions of opioid misuse among American Indian youth and young adults living on or near a reservation.

METHODS

Qualitative in-depth interviews were conducted with N = 18 youth and young adults who were enrolled in a parent research trial focused on American Indian youth suicide prevention. Participants were eligible if they endorsed the use of opioids themselves or by close friends or family members at any point during their trial participation.

FINDINGS

Major themes discussed include: (1) description of opioid use and those who use opioids; (2) acquisition; (3) initiation; (4) motivation to continue using; (5) consequences; and (6) possibilities for intervention. Family played an important role in the initiation of use, but was also highlighted as an important factor in treatment and recovery. A need for upstream prevention methods, including increased employment and after-school activities, was described.

CONCLUSIONS

The insights gained through this work could help to inform treatment and prevention programs in the community. This work is timely due to the pressing urgency of the opioid epidemic nationally, and community capacity to address opioid use locally.

Alcohol use and the gender-specific risk of suicidal behavior: a systematic review and meta-analysis protocol

BACKGROUND

Alcohol use is an important risk factor for suicidal behavior, with a heightened risk found among women. The objective of this study is to determine the gender-specific risk of suicidal behaviors (suicide attempt and death by suicide) for different levels and dimensions of alcohol use-i.e., for (1) average alcohol volume consumed, (2) binge drinking, and (3) individuals with an alcohol use disorder.

METHODS

We will systematically search the available literature for primary studies on the risk relationships specified above. Using a predetermined set of keywords, a comprehensive systematic literature search will be conducted in the following electronic databases: Embase, PsycINFO, PubMed, and Web of Science. The basic inclusion criteria will be (1) an original, quantitative (cohort, case-control or cross-sectional) study; with (2) a measure of risk of at least one dimension of our alcohol exposures in relation to at least one of our outcomes of interest (suicide attempt or death by suicide), and its corresponding measure of variability is reported (or sufficient data to calculate these); and (3) estimates of risk stratified by gender. Studies (1) that use only qualitative labels of alcohol use, and (2) where suicide attempt and non-suicidal self-harm cannot be disaggregated will be excluded. There will be no restrictions on language, geographical region, or year of publication. Two reviewers will independently perform the search and systematic assessment of each identified study and subsequent extraction of data. Categorical random-effects meta-analyses will be conducted to obtain gender-specific pooled risk estimates. Risk of bias will be assessed using the Risk of Bias In Non-randomised Studies-of Interventions tool and the Grading of Recommendations Assessment, Development and Evaluation approach will be used to rate the quality of evidence.

DISCUSSION

This study will synthesize all available data on the gender-specific relationship between various dimensions of alcohol use and suicidal behavior simultaneously in a coherent framework. We will provide risk estimates with the detail needed to better understand the respective risk relationships and appreciate the burden of alcohol-attributable suicide.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022320918.

Association between Psychological Suffering and Suicidal Thinking in Patients with Urologic Cancer Using Real-World Data

Cancer is a leading cause of death in Korea, and depression and suicide are major psychiatric problems in cancer patients. This study aimed to explore the correlation between anxiety, depression, social support, cancer state, and suicidality among urologic cancer patients. Sixty patients with urologic cancer were admitted to a university hospital between October 2019 and February 2020. The patients were evaluated using the Patient Health Questionnaire-9, Generalized Anxiety Disorder 7-item scale, Suicidality module of the Mini International Neuropsychiatric Interview (MINI), and the Lubben Social Network scales (LSNS). To determine which psychological or demographic factors affected suicide risk, Fisher's exact test, Wilcoxon rank-sum test, regression, and logistic regression were conducted. It was found that the greater the depressive symptoms, the higher the suicidal risk (OR = 1.32, 95% CI = 1.08-1.61). Furthermore, anxiety symptoms and the duration of cancer after diagnosis significantly increased depressive symptoms (p = 0.032). Clinicians should be able to identify the risk factors for suicide in patients with cancer, one of which is depression. To assess the risk of suicide, we must evaluate not only depressive symptoms but also the related anxiety and duration of the disease. Prevention and intervention efforts are needed to improve depressive moods and anxiety after cancer diagnosis.

Injury characteristics and circumstances of firearm trauma: Assessing suicide survivors and decedents

INTRODUCTION

Despite representing fewer than 5% of suicide attempts, firearms account for over half of deaths. Yet there is little clinical information regarding firearm attempts, particularly survivors. We assessed clinical factors differentiating firearm suicide survivors from decedents, firearm attempters from other methods, and firearm attempters from similarly injured trauma patients.

METHODS

We used clinical data from the National Trauma Data Bank (2017) to assess firearm suicide attempts using cross-sectional and case-control designs. We used logistic and multinomial regression to compare groups and assess firearm type and discharge destination.

RESULTS

Older age, being uninsured, and injury location were associated with increased mortality among firearm attempters. Older age, White race, male sex, and being uninsured were associated with firearm attempts. Major psychiatric disorders were associated with firearm attempts and using a rifle or shotgun. Major psychiatric disorders, female sex, and smoking were associated with psychiatric discharge. Black and other race were associated with law enforcement discharge, and Black race was associated with lower odds of psychiatric discharge. Uninsured patients had lower odds of discharge to long-term care, psychiatric, or rehabilitation facilities.

CONCLUSIONS

This study identifies factors associated with firearm suicide and includes indicators of disparities in health services for patients at high risk of suicide death.

Sex-specific incidences and risk profiles of suicide mortality in people with alcohol dependence in Taiwan

BACKGROUND AND AIMS

Alcohol-related mental health burden and suicidality impose heavy burdens on global public health. This study measured the sex-specific incidence and risk profiles of suicide mortality in individuals with alcohol dependence in a non-western context.

DESIGN

In this prospective cohort study, individuals with alcohol dependence who were enrollees in Taiwan's National Health Insurance Research database were followed-up over an almost 15-year period. Their data were linked to the national mortality registration database.

SETTING

Taiwan.

PARTICIPANTS

In total, 278 345 patients with alcohol dependence were enrolled and followed-up from 1 January 2001 to 31 December 2016.

MEASUREMENTS

We calculated the incidence and standardized mortality ratio (SMR) of suicide in the cohort and stratified the suicide methods by sex. Sex-specific risk profiles (based on demographic characteristics and physical and psychiatric comorbidities) were generated through Cox proportional hazards regression.

FINDINGS

The suicide rates of men and women were 173.5 and 158.9 per 100 000 person-years, respectively (P = 0.097). The SMR of suicide mortality was more than two times higher in women than in men (6.6 versus 15.0). Women and men adopted different suicide methods. A multivariable Cox proportional hazards regression with a time-varying model revealed that depressive disorder was a common risk factor for suicide in both men and women [adjusted hazard ratio (aHR) = 3.03, 95% confidence interval (CI) = 2.77-3.31 versus aHR = 5.46, 95% CI = 4.65-6.40]. For men, receiving a diagnosis of alcohol dependence between the ages of 25 and 44 years, being unemployed and having schizophrenia, drug-induced mental disorder or sleep disorder were risk factors for suicide.

CONCLUSION

In Taiwan, the incidence of suicide in patients with alcohol dependence is substantially higher than that of the general population. The standardized mortality ratio of suicide in women with alcohol dependence is more than twice that of men with alcohol dependence.

Frequency and correlates of suicidal ideation and behaviors in treatment-seeking Post-9/11 Veterans

OBJECTIVE

Post-9/11 U.S. veterans and servicemembers are at increased risk for suicide, indicating an important need to identify and mitigate suicidal ideation and behaviors in this population.

METHOD

Using data modeling techniques, we examined correlates of suicidal ideation and behavior at intake in 261 Post-9/11 veterans and servicemembers seeking mental health treatment.

RESULTS

Our sample endorsed high rates of suicidal ideation and behavior. Approximately 40% of our sample scored in a range on the Suicide Behaviors Questionnaire-Revised (SBQ-R), indicating high clinical risk for suicide. Results from multivariate analyses indicate that greater state and/or trait depression severity, greater anger and anger expression, less impulse control, and lower rank were consistently associated with suicidal ideation and behavior across our models. Negative posttraumatic thoughts about the self, gender, and military branch of service were also significantly associated with suicidal ideation and behavior.

CONCLUSIONS

Suicidal ideation and behaviors are common in veterans seeking mental health treatment. State and/or trait depression, anger and impulse control were predictors of increased risk for suicidal ideation and behavior across models. Consistencies and differences across models as well as limitations and practical implications for the findings are discussed.

Growing alcohol use preceding death by suicide among women compared with men: age-specific temporal trends, 2003-18

BACKGROUND AND AIMS

In the United States, until 2018 both the prevalence of heavy alcohol use and the suicide mortality rate increased among men and women; however, women had experienced a notably higher increase in both. As heavy alcohol use may have contributed to the observed sex disparity in the suicide mortality rate increase, the aim of the current study was to estimate the temporal trend of the sex- and age-group-specific proportion of suicides that were alcohol-involved in the United States.

DESIGN

Using restricted-access data from the National Violent Death Reporting System, we performed joinpoint regression analyses to investigate temporal trends in the sex- and age-group (young adults = 18-34 years; middle-aged adults = 35-64 years; and older adults = 65+ years)-specific proportion of suicides that were alcohol-involved.

SETTING

United States.

PARTICIPANTS

A total of 115 202 suicide decedents 18+ years of age from 2003 to 2018.

MEASUREMENTS

The sex- and age-group-specific proportion of suicides that were alcohol-involved, among all suicide decedent, for which the decedent had a blood alcohol concentration (BAC) (a) ≥ 0.04 g/dl and (b) ≥ 0.08 g/dl.

FINDINGS

For 2003-18, the proportion of suicides that were alcohol-involved wherein the decedent had a BAC ≥ 0.08 g/day significantly increased on average annually for women of all age groups [young women: 2.80%, 95% confidence interval (CI) = 1.86%, 3.75%; middle-aged women: 2.20%, 95% CI = 1.20%, 3.21%; older women: 10.48%, 95% CI = 1.17%, 20.65%], while only middle-aged men experienced a significant average annual percentage increase (0.81%, 95% CI = 0.003%, 1.62%).

CONCLUSION

In the United States between 2003 and 2018, alcohol use preceding death by suicide increased among women compared with men.

Suicidal ideation and attempt and associated factors among patients with substance use disorder: institution-based cross-sectional study

BACKGROUND

No published research in Ethiopia has examined the prevalence of suicidal ideation and suicide attempts and associated factors among patients with substance use disorder.

AIMS

The main aim of this study was to assess the prevalence of suicidal ideation, suicide attempt and associated factors among patients with substance use disorders.

METHOD

An institution-based cross-sectional study was conducted from 5 May to 13 June 2019 in Addis Ababa. A total of 408 patients were identified using a systematic sampling technique. Data were collected through interviews using the suicidality module of the Composite International Diagnostic Interview. Data were entered into EpiData and analysed using SPSS. Logistic regression analyses were employed. Variables with P < 0.05 were considered to be statistically significant with 95% confidence intervals.

RESULTS

Prevalence rates of suicidal ideation and attempt were found to be 39.5% and 18.6%, respectively. Family history of mental illness (adjusted odds ratio (AOR) = 3.60, 95% CI: 2.17, 5.97), comorbid mental illness (AOR = 3.61, 95% CI: 2.11, 6.16), perceived stigma related to substance misuse (AOR = 4.00, 95% CI: 2.26, 7.07) and alcohol use (AOR = 7.49, 95% CI: 1.99, 28.19) were associated with suicidal ideation. Being female (AOR = 2.46, 95% CI: 1.08, 5.70), family history of suicide (AOR = 3.08, 95% CI: 1.68, 5.64), comorbid mental illness (AOR = 4.09, 95% CI: 2.23, 7.49) and khat use (AOR = 3.73, 95% CI: 1.24, 11.17) were associated with suicide attempt.

CONCLUSIONS

The prevalence of suicidal ideation and attempt were both found to be high. In particular, patients who had a comorbid mental illness were at high risk of both suicidal ideation and attempt. Therefore, special attention should be given to those with a family history of suicide or comorbid mental illness.

Association between clinically recognized suicidality and subsequent initiation or continuation of medications for opioid use disorder

BACKGROUND

Among individuals with opioid use disorder (OUD), medications for OUD (MOUD) may lower suicide risk. Therefore, it is important that individuals with OUD and suicidality receive MOUD. This study examined associations between clinically recognized suicidality and subsequent initiation or continuation of MOUD among patients with OUD in the national Veterans Health Administration (VA).

METHODS

Electronic health record data were extracted for outpatients with OUD who received VA care 10/1/2016-7/31/2017. Suicidality was measured using diagnostic codes for suicidal ideation/attempt and patient record flags. Analyses were conducted separately among patients without prior-year MOUD receipt to examine MOUD initiation, and with prior-year MOUD receipt to examine MOUD continuation. Poisson regression models estimated likelihood of MOUD receipt in the following year for patients with prior-year suicidality relative to those without. Models were adjusted for sociodemographic and clinical characteristics.

RESULTS

Among 20,085 patients with no prior-year MOUD, 12% had suicidality and 12% received MOUD in the following year. Suicidality was positively associated with MOUD initiation (adjusted incidence rate ratio [aIRR]: 1.15, 95% confidence interval [CI]: 1.04-1.28). Among 10,162 patients with prior-year MOUD, 9% had suicidality and 84% received MOUD in the following year. Suicidality was negatively associated with MOUD continuation (aIRR: 0.95, 95% CI 0.91-0.98).

CONCLUSIONS

Among VA patients with OUD, clinically recognized suicidality may increase likelihood of MOUD initiation but decrease likelihood of continuation. Efforts to increase initiation overall and to support retention for patients with suicidality are needed.

Alcohol use history increases the likelihood of suicide behavior among male chronic patients with schizophrenia in a Chinese population

AIMS

This study was designed to detect the association between the history of alcohol drinking and suicidality in schizophrenia (SCZ) inpatients in a Chinese population.

METHODS

We recruited 616 male SCZ inpatients and collected demographic and clinical data. Five-factor model of the Positive and Negative Syndrome Scale (PANSS) was used to assess their psychopathological symptoms.

RESULTS

Our results showed that 31.33% of SCZ patients had a history of alcohol drinking. They had higher rates of lifetime suicide attempt and suicidal ideation than those without a history of alcohol drinking. Moreover, patients with a history of drinking were more likely to attempt suicide (14.51% vs. 7.09%; χ²  = 7.70, df = 1, p = 0.006), with an odds ratio (OR) of 2.22 and have suicidal ideation (29.02% vs. 17.49%; χ²  = 9.89, df = 1, p = 0.002), with an OR of 1.93. In addition, patients who used to drink alcohol were more likely to be smokers and had more severe positive and depressive symptoms (all p < 0.05).

CONCLUSIONS

Our study indicates that history of alcohol drinking may increase the prevalence of lifetime suicide attempt and suicidal ideation in male patients with chronic SCZ. Moreover, the history of alcohol drinking may be associated with some demographic data and clinical symptoms.

Psychoactive substances use before suicide: detailed analysis of all cases that occurred in the Brazilian Federal District in a 10-years period

BACKGROUND

Psychoactive substances (PASs) are an important risk factor for suicide. This study investigated the sociodemographic characteristics, data related to the suicidal behavior, the methods employed, the circumstances of the events, and the use of PASs before dying in all suicides that occurred between 2005-2014 in the Brazilian Federal District, comparing cases with positive and negative detection for PASs in the post-mortem analysis to identify groups at greatest risk.

METHODS

A population-based, observational, cross-sectional study with an analytical aspect was conducted with suicides cases collected from local police, which toxicological examination was performed (headspace gas chromatographic-mass spectrometry-HS-GC/MS) for detection of ethanol and methanol in blood samples; immunoassay for other substances (cocaine, marijuana, benzodiazepine).

RESULTS

The results showed that the increase in the suicide rate was 10 × greater than the population growth, and 44% of the individuals used PASs before suicide. Individuals are more likely to die by suicide at home, be male, have tried before, and change their behavior days before death; they choose to hang as the method and are influenced by alcohol.

CONCLUSION

Identifying what sociodemographic characteristics are associated with a fatal suicide attempt among individuals who use PASs and those who do not use and those who have/do not have mental disorders and what methods are employed could be employed as a path to better interventions. Thus, prevention actions could be planned and directed to individuals with greater risk.

Substance Use Frequency Relates to Suicidal Ideation Through Perceived Burdensomeness and to Suicide Attempts Through Capability for Suicide

BACKGROUND

Although substance use has been linked to both suicidal ideation and suicide attempts, the factors underlying these relations remain unclear. The Interpersonal-Psychological Theory of Suicide (ITS) provides a framework for understanding how substance use may increase suicide risk. The purpose of the current study was to examine if frequency of substance use is indirectly related to suicidal ideation and suicide attempts through core ITS variables (i.e., burdensomeness, thwarted belongingness, and suicide capability).

METHODS

An online sample of Mechanical Turk workers (N = 365) completed measures assessing substance use frequency, burdensomeness, thwarted belongingness, suicide capability, suicidal ideation, and suicide attempts.

RESULTS

After controlling for relevant clinical and demographic covariates, substance use frequency was indirectly related to suicidal ideation through burdensomeness but not thwarted belongingness. Substance use frequency was indirectly related to suicide attempts through suicide capability only.

LIMITATIONS

The cross-sectional design precludes conclusions about the precise nature and direction of the relations examined. The use of a community sample limits generalizability to more severe substance using samples.

CONCLUSIONS

Results highlight the relevance of distinct ITS factors in the relation between substance use frequency and both suicidal ideation and suicide attempts. Results may inform specific targets for novel interventions aimed at reducing suicide risk among substance-using individuals.HighlightsSubstance use frequency was indirectly related to SI through burdensomeness.Substance use frequency was not indirectly related to SI through thwarted belongingness.Substance use frequency was indirectly related to SA only through suicide capability.

Risk of self-harm or suicide associated with specific drug use disorders, 2004-2016: a population-based cohort study

BACKGROUND AND AIMS

Drug use disorders are associated with increased risk of self-harm. Risk differences associated with specific types of drug use disorders are yet to be comprehensively reported. This study aimed to examine the risk of self-harm or suicide associated with different drug use disorders in Hong Kong.

DESIGN

Population-based cohort study.

SETTING

The Clinical Data Analysis and Reporting System (CDARS) managed by the Hong Kong Hospital Authority.

PARTICIPANTS

Cases were people ages 10 years or older who visited a hospital Accident and Emergency department between 1 January, 2004 and 31 December, 2016 with any of 10 specific drug use disorders (comprising opioid; ketamine; methamphetamine; sedative, hypnotic, or anxiolytic; amphetamine or related stimulant; cocaine; cannabis; hallucinogen; unspecified or other drug; and polydrug). Each case was matched with two controls, selected from a subset of people in CDARS sharing the same gender, age and psychiatric profile. A total of 8270 cases and 16 540 matched controls were included.

MEASUREMENTS

Incidence and adjusted hazard ratio (aHR) of subsequent self-harm or suicide for each specific drug use disorder were estimated.

FINDINGS

The most prevalent drug use disorder was opioid use disorder (2523; 30.51%) and the least prevalent was hallucinogen use disorder (77; 0.93%). The crude incidence of self-harm or suicide ranged from 26.57 (95% CI, 14.23-44.55) per 1000 person-years for cannabis use disorder to 91.97 (77.32-108.37) for polydrug use disorder. The highest risk of self-harm or suicide was observed in ketamine (aHR, 16.36; 95% CI, 11.03-24.29) and opioid (15.97; 10.73-23.23) use disorders.

CONCLUSIONS

In Hong Kong, all types of drug use disorders appear to be significantly associated with increased risk of self-harm or suicide, but risk levels vary by type of drug use disorder.

Suicide Deaths Among Women in California Living With Handgun Owners vs Those Living With Other Adults in Handgun-Free Homes, 2004-2016

Importance

Little is known about the extent to which secondhand exposure to household firearms is associated with risk of suicide in adults who do not own guns, most of whom are women.

Objective

To evaluate changes in risk of suicide among women living in gun-free households after one of their cohabitants became a handgun owner.

Design, Setting, and Participants

This cohort study observed participants for up to 12 years and 2 months from October 18, 2004, to December 31, 2016. Data were analyzed from April to November 2021. The study population included 9.5 million adult women in California who did not own guns and who entered the study while living with 1 or more adults in a handgun-free home.

Exposures

Secondhand exposure to household handguns.

Main Outcomes and Measures

Suicide, firearm suicide, nonfirearm suicide.

Results

Of 9.5 million women living in handgun-free homes, 331 968 women (3.5% of the study population; mean [SD] age, 41.6 [18.0] years) became exposed to household handguns during the study period. In the entire study population, 294 959 women died: 2197 (1%) of these were by suicide, 337 (15%) of which were suicides by firearm. Rates of suicide by any method during follow-up were higher among cohort members residing with handgun owners compared with those residing in handgun-free homes (hazard ratio, 1.43; 95% CI, 1.11-1.84). The excess suicide rate was accounted for by higher rates of suicide by firearm (hazard ratio, 4.32; 95% CI, 2.89-6.46). Women in households with and without handguns had similar rates of suicide by nonfirearm methods (hazard ratio, 0.90; 95% CI, 0.63-1.27).

Conclusions and Relevance

In this study, the rate of suicide among women was significantly higher after a cohabitant of theirs became a handgun owner compared with the rate observed while they lived in handgun-free homes.