Effect of alcohol interventions on suicidal ideation and behaviour: A systematic review and meta-analysis

Relationship Between Alcohol Use and Firearm-Involved Suicide: Findings From the National Violent Death Reporting System, 2003-2020

INTRODUCTION

Acute alcohol intoxication is a contributing factor in firearm-involved suicides. However, knowledge of the relationship between alcohol intoxication and firearm-involved suicide by age and sex (defined herein as the biological sex of the decedent) is limited. The purpose of the current study was to evaluate the sex- and age group-specific relationship between alcohol intoxication and firearm-involved suicide.

METHODS

Data from the National Violent Death Reporting System, 2003-2020, on suicide decedents (18+ years of age) were utilized. Age-group- and sex-specific multivariate binary logistic regression analyses were conducted. Statistical analyses were performed in 2023.

RESULTS

Alcohol intoxication (i.e., having a blood alcohol concentration of 0.08 g/dL or more) was significantly associated with using a firearm as the method of suicide for young (18-34 years; relative risk (RR)=1.31, 95% CI: 1.22-1.40) and middle-aged (35-64 years; RR=1.34, 95% CI: 1.27-1.39) females but not among older females (65+ years; RR=1.01, 95% CI: 0.87-1.17). Among males, the association was significant for all age-groups (young: RR=1.28, 95% CI: 1.25-1.30; middle-aged: RR=1.17, 95% CI: 1.15-1.19; and older: RR=1.04, 95% CI: 1.01-1.07).

CONCLUSIONS

Among males of all ages and young and middle-aged females, alcohol intoxication was associated with increased risk of suicide by firearm-an extremely lethal method that accounts for a majority of suicides in the U.S.-compared to their non-intoxicated counterparts. Interventions targeting excessive alcohol consumption may be effective in reducing suicide mortality rates.

Clinical Trials Studying Suicide Risk Reduction: Who is Excluded From Participation

OBJECTIVE

The use of exclusion criteria in clinical trials can cause research participants to differ markedly from clinical populations, which negatively impacts generalizability of results. This study identifies and quantifies common and recurring exclusion criteria in clinical trials studying suicide risk reduction, and estimates their impact on eligibility among a clinical sample of adults in an emergency department with high suicide risk.

METHOD

Recent trials were identified by searching PubMed (terms suicide, efficacy, effectiveness, limited to clinical trials in prior 5 years). Common exclusion criteria were identified using Qualitative Content Analysis. A retrospective chart review examined a one-month sample of all adults receiving psychiatric evaluation in a large urban academic emergency department.

RESULTS

The search yielded 27 unique clinical trials studying suicide risk reduction as a primary or secondary outcome. After research fundamentals (e.g. informed consent, language fluency), the most common exclusion criteria involved psychosis (77.8%), cognitive problems (66.7%), and substance use (63.0%). In the clinical sample of adults with high suicide risk (N = 232), psychosis exclusions would exclude 53.0% of patients and substance use exclusions would exclude 67.2% of patients. Overall, 5.6% of emergency psychiatry patients would be eligible for clinical trials that use common exclusion criteria.

CONCLUSIONS

Recent clinical trials studying suicide risk reduction have low generalizability to emergency psychiatry patients with high suicide risk. Trials enrolling persons with psychosis and substance use in particular are needed to improve generalizability to this clinical population.

Proximity of alcohol outlets and presentation to hospital by young people after self-harm: A retrospective geospatial study using the integrated data infrastructure

OBJECTIVES

There is a well-established association between alcohol use, misuse, intoxication and self-harm, the latter of which is associated with suicide. This study aimed to better understand the association between proximity to alcohol outlets and the likelihood of young people presenting to hospital following self-harm.

METHODS

This was a nationwide retrospective geospatial study using data from the New Zealand Integrated Data Infrastructure using population-level data for 10-29-year-olds for the 2018 and 2017 calendar years. Presentations to hospital following self-harm were identified using the national minimum data set. Proximity to alcohol outlets was defined in road network distance (in kilometres) and ascertained using Integrated Data Infrastructure geospatial data. Alternative measures of proximity were employed in sensitivity analyses. Complete-case two-level random intercept logistic regression models were used to estimate the relationship between alcohol outlet proximity and hospital presentation for self-harm. Adjusted models included sex, age, ethnicity, area-level deprivation, urbanicity and distance to nearest medical facility. Analyses were also stratified by urbanicity.

RESULTS

Of the 1,285,368 individuals (mean [standard deviation] age 20.0 [5.9] years), 7944 (0.6%) were admitted to hospital for self-harm. Overall, the odds of presenting to hospital for self-harm significantly decreased as the distance from the nearest alcohol outlet increased, including in adjusted models (adjusted odds ratio 0.980; 95% confidence interval = [0.969-0.992]); the association was robust to changes in the measure of alcohol proximity. The effect direction was consistent across all categorisations of urbanicity, but only statistically significant in large urban areas and rural areas.

CONCLUSIONS

The findings of this study show a clear association between young people's access to alcohol outlets and presentation to hospital for self-harm and may provide a mandate for government policies and universal interventions to reduce young people's access to alcohol outlets. Further research regarding causative mechanisms is needed.

New insights into the molecular basis of alcohol abstinence and relapse in alcohol-associated liver disease

Alcohol use disorder remains a significant public health concern, affecting around 5% of adults worldwide. Novel pathways of damage have been described during the last years, providing insight into the mechanism of injury due to alcohol misuse beyond the direct effect of ethanol byproducts on the liver parenchyma and neurobehavioral mechanisms. Thus, the gut-liver-brain axis and immune system involvement could be therapeutic targets for alcohol use disorder. In particular, changes in gut microbiota composition and function, and bile acid homeostasis, have been shown with alcohol consumption and cessation. Alcohol can also directly disrupt intestinal and blood-brain barriers. Activation of the immune system can be triggered by intestinal barrier dysfunction and translocation of bacteria, pathogen-associated molecular patterns (such as lipopolysaccharide), cytokines, and damage-associated molecular patterns. These factors, in turn, promote liver and brain inflammation and the progression of liver fibrosis. Other involved mechanisms include oxidative stress, apoptosis, autophagy, and the release of extracellular vesicles and miRNA from hepatocytes. Potential therapeutic targets include gut microbiota (probiotics and fecal microbiota transplantation), neuroinflammatory pathways, as well as neuroendocrine pathways, for example, the ghrelin system (ghrelin receptor blockade), incretin mimetics (glucagon-like peptide-1 analogs), and the mineralocorticoid receptor system (spironolactone). In addition, support with psychological and behavioral treatments is essential to address the multiple dimensions of alcohol use disorder. In the future, a personalized approach considering these novel targets can contribute to significantly decreasing the alcohol-associated burden of disease.

Implementing Evidence-Based Suicide Prevention Strategies for Greatest Impact

Suicide remains a leading cause of death in the United States and globally. In this review, epidemiological trends in mortality and suicide risk are presented, with consideration given to the impact of the COVID-19 pandemic. A public health model of suicide prevention with a community and clinical framework, along with advances in scientific discovery, offer new solutions that await widespread implementation. Actionable interventions with evidence for reducing risk for suicidal behavior are presented, including universal and targeted strategies at community, public policy, and clinical levels. Clinical interventions include screening and risk assessment; brief interventions (e.g., safety planning, education, and lethal means counseling) that can be done in primary care, emergency, and behavioral health settings; psychotherapies (cognitive-behavioral, dialectical behavior, mentalization therapy); pharmacotherapy; and systemwide procedures for health care organizations (training, policies, workflow, surveillance of suicide indicators, use of health records for screening, care steps). Suicide prevention strategies must be prioritized and implemented at scale for greatest impact.

Longitudinal and self-attributed change in alcohol use among young adults during the COVID-19 pandemic in Australia

INTRODUCTION

The COVID-19 pandemic introduced a unique concern regarding the potential for pandemic-related increases in alcohol use. However, most studies which have measured pandemic-related changes to date utilise self-attribution measures of changes in alcohol use using cross-sectional designs, which rely on accurate self-attributions for validity. There has been minimal investigation of correspondence of self-attributed and longitudinally measured changes in alcohol use during the pandemic. The current study seeks to examine this correspondence.

METHODS

A total of 856 participants originally recruited from Australian secondary schools completed follow-up surveys of an ongoing study at two timepoints (2018-2019, mean age 18.6 and 2020-2021, mean age 19.9; 65.3% female). Alcohol use was measured as any drinking (1+ drinks) and binge drinking (5+ drinks) frequency in the past 6 months. The correspondence and relationship between 'longitudinal change' measured from the first to the second timepoint and 'self-attributed change' measured at the second timepoint were examined.

RESULTS

For both any drinking and binge drinking frequency, moderate correspondence was observed between self-attributed and longitudinal change in drinking (37.1% and 39.3%). Most participants with longitudinal increases in any drinking or binge drinking frequency failed to correctly self-attribute this increase.

DISCUSSION AND CONCLUSIONS

The findings suggest that self-attributed increases do not correspond well with longitudinally measured increases in pandemic-related drinking and may underestimate increases measured longitudinally. Method of measurement needs to be taken into account if data are to be used to identify sub-groups at risk of alcohol use increases and facilitate appropriate direction of public health efforts.

A Systematic Review of School-Based Suicide Prevention Interventions for Adolescents, and Intervention and Contextual Factors in Prevention

Suicide is the fourth leading cause of death among adolescents, globally. Though post-primary, school-based suicide prevention (PSSP) has the potential to be a key strategy for preventing adolescent suicidal thoughts and behaviours (STBs), there are persisting challenges to translating PSSP research to practice. Intervention and contextual factors relevant to PSSP are likely key to both PSSP effectiveness and implementation. As such, this systematic review aimed to summarise the effectiveness of PSSP for adolescent STBs and highlight important intervention and contextual factors with respect to PSSP. PsycINFO, Medline, Education Source, ERIC, Web of Science, and the Cochrane Central Register of Controlled Trials were searched to identify randomised and non-randomised studies evaluating the effectiveness of interventions located in post-primary, school-based settings targeting adolescent STBs. PSSP effectiveness and intervention and contextual factors were synthesised narratively. Twenty-eight studies were retained, containing nearly 47,000 participants. Twelve out of twenty-nine trials comparing intervention and independent control comparators reported statistically significant reductions in STBs postintervention, and 5/7 trials comparing preintervention and postintervention scores demonstrated significant reductions in STBs over time. Reporting and analysis of intervention and contextual factors were lacking across studies, but PSSP effectiveness and intervention acceptability varied across type of school. Although school personnel commonly delivered PSSP interventions, their input and perspectives on PSSP interventions were lacking. Notably, adolescents had little involvement in designing, inputting on, delivering and sharing their perspectives on PSSP interventions. Twenty out of twenty-eight studies were rated as moderate/high risk of bias, with non-randomised trials demonstrating greater risks of bias and trial effectiveness, in comparison to cluster randomised trials. Future research should prioritise complete reporting and analysis of intervention and contextual factors with respect to PSSP, involving key stakeholders (including adolescents and school personnel) in PSSP, and investigating key stakeholders' perspectives on PSSP. Given the inverse associations between both study quality and study design with PSSP effectiveness, particular consideration to study quality and design in PSSP research is needed. Future practice should consider PSSP interventions with universal components and PSSP which supports and involves key stakeholders in engaging with PSSP.

The association between alcohol use disorder and suicidal ideation in a New Zealand birth cohort

BACKGROUND

Alcohol use disorder is associated with increased suicide risk; however, both alcohol use disorder and suicide share risk factors which must be accounted for in order to understand this relationship. This study aimed to explore the longitudinal relationship between alcohol use disorder and suicidal ideation in adulthood, while accounting for both child background and adult covariate factors.

METHOD

Data were collected from the Christchurch Health and Development Study, a birth cohort of 1265 children born in Christchurch (New Zealand) in mid-1977. Alcohol use disorder (operationalised as alcohol abuse and alcohol dependence) was quantified between age 18 and 40 in five data waves. The outcome measure suicidal ideation was reported over the same time periods. Childhood confounding variables were controlled for, as well as time-dynamic covariates collected in adulthood, including internalising disorders, distress due to relationship dissolutions and other substance use disorders.

RESULTS

The association between alcohol abuse and suicidal ideation was not statistically significant before or after adjusting for childhood confounding and adulthood covariate factors, when compared to no alcohol disorder. However, the association between alcohol dependence and suicidal ideation was significant both before and after adjustment (unadjusted odds ratio = 2.89, 95% confidence interval = [2.09, 3.99]; adjusted odds ratio = 1.52, 95% confidence interval = [1.04, 2.23]), when compared to no alcohol disorder. Furthermore, alcohol dependence remained significant when compared to alcohol abuse (unadjusted odds ratio = 2.33, 95% confidence interval = [1.61, 3.37]; adjusted odds ratio = 1.54, 95% confidence interval = [1.00, 2.37]).

CONCLUSION

This analysis found an association between alcohol dependence and suicidal ideation within a New Zealand birth cohort, which persists even after adjustment for childhood confounding and adulthood covariate factors. Given the high rates of suicide and heavy drinking within the New Zealand population, any comprehensive national or regional suicide prevention plan should seek to reduce risky alcohol consumption at an individual and population level, as this represents a modifiable risk factor for suicide.

Developmental Relations Between Bullying Victimization and Suicidal Ideation in Middle Adolescence and Emerging Adulthood: Do Internalizing Problems and Substance Use Mediate Their Links?

Previous research has suggested that bullying victimization is associated with higher suicidal risk among young people; however, the mechanisms underlying this relation have not been well examined. The current study aimed to illuminate the developmental links between bullying victimization and suicidal ideation by examining the mediating roles of depressive symptoms, anxiety symptoms, and substance use. The study sample consisted of n = 1465 participants (51.7% male) from the normative z-proso study. Using random intercept cross-lagged panel models and three waves of longitudinal data (ages 15, 17, and 20), the hypothesized mediation effects at the within-person level were tested while partialling out between-person confounds. The results suggested that, at the within-person level, bullying victimization did not predict subsequent suicidal ideation via depressive symptoms, anxiety symptoms, or substance use. However, age 15 bullying victimization predicted within-person increases in age 17 depressive symptoms and suicidal ideation. In addition, depressive symptoms at age 15 and tobacco and cannabis use at age 17 were associated with within-person increases in bullying victimization at ages 17 and 20, respectively. The results also indicated that cannabis use and suicidal ideation were positively and reciprocally related over time. Future studies collecting data at multiple timescales are needed to understand proximal and longer-term mechanisms underlying the relation between bullying victimization and suicidality.