Self-poisoning and alcohol

Dosage sensitivity and exon shuffling shape the landscape of polymorphic duplicates in Drosophila and humans

Despite polymorphic duplicate genes' importance for the early stages of duplicate gene evolution, they are less studied than old gene duplicates. Two essential questions thus remain poorly addressed: how does dosage sensitivity, imposed by stoichiometry in protein complexes or by X chromosome dosage compensation, affect the emergence of complete duplicate genes? Do introns facilitate intergenic and intragenic chimaerism as predicted by the theory of exon shuffling? Here, we analysed new data for Drosophila and public data for humans, to characterize polymorphic duplicate genes with respect to dosage, exon-intron structures and allele frequencies. We found that complete duplicate genes are under dosage constraint induced by protein stoichiometry but potentially tolerated by X chromosome dosage compensation. We also found that in the intron-rich human genome, gene fusions and intragenic duplications extensively use intronic breakpoints generating in-frame proteins, in accordance with the theory of exon shuffling. Finally, we found that only a small proportion of complete or partial duplicates are at high frequencies, indicating the deleterious nature of dosage or gene structural changes. Altogether, we demonstrate how mechanistic factors including dosage sensitivity and exon-intron structure shape the short-term functional consequences of gene duplication.

Changing Ethnic and Social Characteristics of Patients Admitted for Self-Poisoning in West London during 1971/2 and 1983/4

The characteristics of adult patients admitted for self-poisoning to an inner London district general hospital were examined during 1971/72 and 1983/84. The incidence of self-poisoning halved over the 12 years, from 326 to 178 per 100 000. Although no West Indians were admitted in the first period, they comprised 7% of such admissions 12 years later. The West Indian population in the catchment area remained constant at around 6%. Amongst all patients admitted for self-poisoning, there was a fall in the number of patients diagnosed as depressed, having a personality disorder or admitting to prior psychiatric care, but an increase in alcoholism. Paracetamol became more common as a drug used in self-poisoning and barbiturates were taken less often. Only one patient died in the series. These results should stimulate more soundly based epidemiological studies on ethnic variation in self-poisoning, and on self-injury in inner-city areas.

A survey of opinions on the management of individuals who express suicidal ideation while intoxicated with alcohol

Aims and Method

It was noted that approaches to the assessment and management of individuals intoxicated with alcohol who express suicidal ideation varied widely. This study explored what guidance is currently available and sought the opinions of 218 junior and senior psychiatrists.

Results

The Royal College of Psychiatrists has no specific guidelines on this issue, but the Medical Defence Union and Scottish Central Legal Office gave opinion regarding a psychiatrist's duty of care and clinical responsibilities. This information did not reflect the opinions of the psychiatrists canvassed. There was no consensus among the 65% of clinicians who responded to the survey.

Clinical Implications

There is a need for greater clarity and guidance on the management of individuals who are intoxicated and express acute suicidal ideation. Sharing of good practice guidelines and greater integration of local and national policies is needed. It is certainly a topic worthy of inclusion in all induction days for junior psychiatrists.

Pattern of acute drug poisoning in Oslo

All 1742 admissions occasioned by acute drug poisoning to a medical ward in Oslo during the periods 1958--60, 1963--65, 1966--69 and 1970--73 have been reviewed. The number of admissions per annum in these periods was 99, 119, 128 and 144, respectively. Because the hospital situation and number of inhabitants in the city remained fairly constant from 1958 to 1973, the increasing figures were assumed to reflect a corresponding increase in the incidence of acute drug poisoning in Oslo. The incidence was estimated to be within the range of 1--2 per 1000 inhabitants per annum. No female predominance was noted except for the age group under 30 years. The occurrence of barbiturate poisonings decreased markedly during the peroids studied, whereas those due to non-barbiturate hypnotics, tranquillizers and tricyclic antidepressants showed a proportionate increase. Slightly less than one fourth of the females and half of the males had taken alcohol. More males (43%) than females (13%) also were alcoholics. A suicidal intention was, however, found more frequently among females (70%) than males (43%). The hospital mortality was approximately 1 %. No death was associated with tricyclic antidepressants, which in the last study period had been ingested by approximately 10% of all patients.

Alcohol exposure and paracetamol-induced hepatotoxicity

Most instances of hepatotoxicity due to paracetamol in the United Kingdom and Australia are the result of large overdoses of the drug taken with suicidal or parasuicidal intent. In contrast, serious hepatotoxicity at recommended or near-recommended doses for therapeutic purposes has been reported, mainly from the United States and in association with chronic alcohol use, leading to the widely held belief that chronic alcoholics are predisposed to paracetamol-related toxicity at relatively low doses. Yet the effects of alcohol on paracetamol metabolism are complex. Studies performed in both experimental animals and humans indicate that chronic alcohol use leads to a short-term, two- to threefold increase in hepatic content of cytochrome P4502E1, the major isoform responsible for the generation of the toxic metabolite from paracetamol, although increased oxidative metabolism of paracetamol at recommended doses has not been demonstrated clinically. A reduced hepatic content of glutathione, required to detoxify the reactive metabolite, has been documented in chronic alcoholics, due probably to associated fasting and malnutrition, providing a metabolic basis for any possible predisposition of this group to hepatotoxicity at relatively low paracetamol doses. Simultaneous alcohol and paracetamol ingestion reduces oxidative metabolism of paracetamol in both rodents and humans, predominantly as a consequence of depletion in cytosol of free NADPH. The possibilities that chronic alcohol use may predispose to paracetamol-related hepatotoxicity and that alcohol taken with paracetamol may protect against it, based on these metabolic observations, are examined in this review.

Gender differences in adolescent psychiatric outpatient substance use: associated behaviors and feelings

OBJECTIVE

To investigate gender differences in substance use and associated high-risk behaviors and feeling states in 220 adolescent psychiatric outpatients.

METHOD

One hundred seven females and 113 males with a mean age of 15.6 (SD +/- 1.4), seen in a tertiary care center adolescent psychiatry clinic, completed scales tapping substance use and associated feelings and behaviors. Approximately half had used nicotine and alcohol, one third had used marijuana, and 10% reported narcotic use.

RESULTS

Conduct disorder behavior, suicidality, and impulsivity scale scores decreased with age in females while marijuana use, conduct disorder behavior, and Hypophoria scale scores increased with age in males. Alcohol use in males, as contrasted with females, correlated more significantly with other substance use and high-risk behaviors. Suicidality tended to correlate more with polysubstance use in females and with sexual behaviors in females only. Substance use correlated with the Impulsivity and Need scale scores in males and scores on the Sociopathy scale in females.

CONCLUSIONS

Substance use in males correlates with high-risk behaviors and is associated with feelings of impulsivity and need. Substance use correlates with self-destructive behaviors and sociopathic feelings in females. There is evidence of more persistent high-risk behaviors, including substance use, in males than in females.

Suicide attempts in which alcohol is involved: a special group in general hospital emergency rooms

Sixty-two percent of 1018 parasuicide patients treated in the emergency room of Helsinki University Central Hospital in 1983 for 1207 suicide attempts had recently consumed alcohol in addition to medical drugs: 46% were women and 54% men. High body alcohol levels were associated with young age and male gender. Alcohol consumption shortly before, or at the time of, parasuicidal acts was more common among young or lonely men with previous suicide attempts. Their suicide risk was assessed as less severe and they were less often referred to a psychiatrist compared with those who had not consumed alcohol. They were also more often left without arranged after-care. By the end of a 5.5-year follow-up period, 3.3% of these alcohol consumers had committed suicide, an annual suicide mortality of 598/100,000. In the year following the initial attempt, suicide mortality was 1809/100,000, a 51-fold risk compared to that of the total population in Helsinki. Sixty-seven percent of alcohol consumers during the initial suicide attempt also took it before actually committing suicide, and 30% of these revealed clear evidence of chronic alcohol consumption. Those who initially consumed alcohol were identifiable as a risk group for suicide, and thus improvement in their recognition and treatment in the emergency rooms of general hospitals is recommended.

Parasuicide and alcohol: a 20 year survey of admissions to a regional poisoning treatment centre

The relationship between alcohol dependence, alcohol consumption and parasuicide was studied among patients admitted over a twenty year period (1968-87) to a regional poisoning treatment centre in Edinburgh. Both alcohol dependence and consumption of alcohol at the time of the parasuicidal act were reported more commonly by men than by women. An examination of temporal trends showed little change among male patients, while the proportion of females diagnosed as alcohol dependent or consuming alcohol at the time of the act tended to increase over time. A comparison of alcohol dependent (AD) and non-alcohol dependent (non-AD) parasuicides over the period 1982-87 revealed differences in respect of sociodemographic characteristics (the AD group containing more unemployed, especially long term) clinical variables (the AD group being more likely to have acted suicidally and to have received psychiatric treatment in the past, yet less likely to be currently diagnosed psychiatrically ill), family features and social problems. The implications of the study findings for research and service delivery are mentioned.

Female alcoholics. I. Alcohol dependence and problems associated with prescribed psychotropic drug use

A case note study of 518 alcohol-dependent (DSM-III) inpatients examined their reported past history of prescribed psychotropic drug use patterns between 1973-1985. The subjects were cross-matched for gender, age and admission date and stratified into 3 time periods. The characteristics of psychotropic medication recipients were compared with those patients who reported no use of licit medications. Statistical analysis by logistic regression indicated that there was a significant relationship between the past use of psychotropic drugs with a parental history of excessive alcohol intake, the higher levels of MAST scores and the occurrence of past parasuicide events. Patients in their middle years (35-54) tended to have received significantly less psychotropic drugs than the younger or older age groups. The female (70%) to male (48%) ratio of past psychotropic use was 1.4:1. Gender differences were also noted in the use of antidepressants and illicit substances.

Who commits suicide after a suicide attempt? An 8 to 10 year follow up in a suburban catchment area

One hundred and sixty-three individuals in a suburban catchment area of 72,000 inhabitants made registered suicide attempts during 1975-1976 (i.e. 159/100,000 greater than or equal to 18 years). They were followed up by means of the Swedish Register of Death Causes over a period of 8-10 years. Police reports, autopsies and psychiatric records were also studied. Six cases of verified suicide were found and four additional cases were considered as probable or possible suicides. Thus the cumulative rate over 8-10 years was 3.7-6.1%. There was a mean number of 3.5 suicide attempts before the eventual suicide. The most important common factor overall was alcohol or drug abuse with social deterioration (seven in 10 cases). The rest (three in 10 cases) were depressed women with long-standing suicidal processes. The importance of recognizing chronic abuse as probably the most important background factor is stressed. The total group encompasses individuals with longstanding and severe life problems and difficulties in relating to society. The realistic chances of being able to provide effective suicide prophylaxes for most of these patients requires well planned and longstanding treatment and rehabilitation programmes.

Age and self-poisoning: the epidemiology in Newcastle upon Tyne in the 1980s

The epidemiology of 737 consecutive self-poisoning admissions to Freeman Hospital, Newcastle upon Tyne, has been investigated with reference to age in young (less than 35), mid-aged (35-64) and elderly (greater than or equal to 65 year) patients. The most important differences were increased formal psychiatric illness in the elderly, demonstrated by increased likelihood of admission to psychiatric units; less likelihood of overdose with multiple agents in the elderly, and less use of alcohol. There were also differences in the types of drugs used. The youngest patients took more paracetamol and less psychoactive drugs and more of their drugs were prescribed for a relative than the other two groups. The elderly were much less likely to receive gastric lavage or emesis and more likely to receive supportive treatment only than younger patients. This difference may, in part, be explained by the more frequent occurrence of benzodiazepine poisoning in those over 65 years.

The epidemiology of deliberate self-harm. The Ibadan experience

In a 6-month prospective study of the three main general hospitals in Ibadan, Nigeria, 39 cases of deliberate self-harm were reported out of a total 23,859 subjects attending the sections of hospital studied. Thirty (76.9%) were under 30 years of age and 36 (86.3%) were under 34 years of age. The male to female ratio was 1.4.1: more than half of the population (51.3%) were students and 25.6%, manual workers. The methods used were mainly ingestion of chemicals (24 patients) and psychotropic drugs (11 patients). Disturbed interpersonal relationships, especially with parents, were mainly found to have motivated the acts. The implications of these findings are discussed.

Serum alcohol levels, toxicology screens, and use of the breath alcohol analyzer

The emergency physician sees a large number of patients with problems related to the ingestion of alcohol, drugs, and toxins, and must be prepared to deal with them in an efficient and cost-effective manner. This article discusses a rationale for ordering serum alcohol levels and toxicology screens, as well as use of the breath alcohol analyzer. A serum alcohol level should be reserved for patients in whom the alcohol level is necessary to confirm a diagnosis or to guide treatment. An alcohol level is indicated when alcohol use is combined with a significant alteration in mental status, multiple drug overdose, head injury, coma, major trauma, seizures, or psychosis. The breath alcohol analyzer is useful when rapid determination of alcohol levels is desired, particularly with coma or coexisting head trauma. A low or negative level in this case rapidly alerts the physician to the presence of another condition that may require additional testing. Toxicology screening should be performed when suspected drug or toxin ingestion is combined with coma, convulsions, head injury with altered mental status, unstable vital signs, alterations in acid-base or electrolyte status, or psychosis. The screen also may be used to determine the need for a specific antidote or means of increasing excretion of a toxin, or to determine the presence of a drug that should be quantified to guide management. Open communication with the laboratory and the use of rapid screening tests markedly increase the benefit of toxicology screening.

Unemployment and suicidal behaviour: a review of the literature

In order to provide a framework for reviewing the voluminous literature on unemployment and suicidal behaviour, the author distinguishes between two categories of deliberately self-harmful act: those with fatal outcome (suicide) and those with non-fatal outcome (parasuicide); and differentiates four major types of quantitative research report: individual--cross-sectional; aggregate--cross-sectional; individual--longitudinal; and aggregate--longitudinal. Methodological issues and empirical research findings are discussed separately for each type of study and each category of deliberate self-harm. Cross-sectional individual studies reveal that significantly more parasuicides and suicides are unemployed than would be expected among general population samples. Likewise, parasuicide and suicide rates among the unemployed are always considerably higher than among the employed. Aggregate--cross-sectional studies provide no evidence of a consistent relationship between unemployment and completed suicide, but a significant geographical association between unemployment and parasuicide was found. Results from all but one of the individual longitudinal studies point to significantly more unemployment, job instability and occupational problems among suicides compared to non-suicides. The aggregate longitudinal analyses reveal a significant positive association between unemployment and suicide in the United States of America and some European countries. The negative relationship in Great Britain during the 1960s and early 1970s has been shown to result from a unique decline in suicide rates due to the unavailability of the most common method of suicide. However, despite the firm evidence of an association between unemployment and suicidal behaviour, the nature of this association remains highly problematic. On the basis of the available date, the author suggests that macro-economic conditions, although not directly influencing the suicide rate, may nevertheless constitute an important antecedent variable in the causal chain leading to self-harmful behaviour. Further empirical research based on a longitudinal design is recommended as a matter of urgency so that a more definitive assessment of the aetiological significance of unemployment in parasuicide may be made.

Breath alcohol analysis in the Accident and Emergency Department

Breath alcohol analysis was undertaken in 1044 consecutive patients aged over 15 years attending the Accident and Emergency (A and E) Department of a rural district general hospital during a 50-day period. 16.5 per cent of all patients had the smell of alcohol on their breath, with 10.2 per cent of the patients recording a breath alcohol level equivalent to a blood level of 80 mg/100 ml or more. One-third of all patients attending between 9 pm and midnight, and almost two-thirds of patients attending between midnight and 3 am had positive breath tests. Positive breath tests were most likely in males, patients with head injuries, with overdoses, in victims of assault and in patients with a depressed conscious level, irrespective of cause. Clinical estimation of intoxication by alcohol may be accurate in the co-operative patient, but in the patient with a head injury or with a depressed conscious level from another cause, this is more difficult. Breath alcohol analysis is rapid, not-invasive, accurate and of clinical value in these and other high-risk patients attending hospital as emergencies.

Alcohol in association with suicide and attempted suicide in young women

The use of alcohol in suicidal behaviour in young women, aged from 18 to 30 years, does not appear to be exceptional when compared to reports of its general community use. Significantly fewer patients who made suicide attempts with a high physical risk to life reported the use of alcohol either in general, or with their suicide attempt. Although it has long been assumed that alcohol bears a causal relationship to suicidal behaviour, inquiry into specific groups of suicidal subjects appears to be indicated.

Alcohol and the emergency service patient

To determine the prevalence of alcohol use in casualty patients breath-alcohol analysis was performed on 702 patients attending the accident and emergency department of a large teaching hospital during the evening. Forty per cent of patients had consumed alcohol before attending and 32% had a blood alcohol concentration exceeding 17.4 mmol/l (80 mg/100 ml). Clinical assessment of intoxication resulted in a false-negative diagnosis in 10% of inebriated patients, indicating that an objective measurement of the blood alcohol concentration by a test, such as breath-alcohol analysis, may be of additional value. These findings confirm that a high proportion of emergency-service patients are affected by alcohol and suggest that alcoholism treatment facilities need to be integrated with accident and emergency services.

Self-poisoning--a complication of epilepsy

From 1972 to 1976 130 epileptics presented 171 times to the Western Infirmary, Glasgow, as medical emergencies with self-poisoning. They constituted 3.5 per cent of 3,733 patients poisoning themselves on 4,121 occasions. Repetition of self-poisoning was commoner in epileptics (18.5 per cent) than in non-epileptics (7.0 per cent). The 130 epileptics have been compared with a non-epileptic group of self-poisoners matched for age, sex, and number of repetitions and have been found to have less alcohol excess but significantly more psychopathy. Possible explanations and prophylactic measures are discussed. In view of the relative incidence of epilepsy and self-poisoning in the community, and of epilepsy among self-poisoners in this and other studies, it is concluded that self-poisoning is a common complication of epilepsy.

Attitudes towards self-poisoning

Self-poisoning now constitutes one of the prime emergencies in hospital medical practice. This paper describes the results of the study of the attitudes of physicians and senior nurses towards several common illnesses in the medical wards. The junior doctors and the nurses who frequently have primary responsibility for the care of the self-poisoners tend to show unfavourable attitudes towards these patients.

On the prevention of parasuicide

Parasuicide rates have shown a marked increase in recent years and now consume a substantial proportion of medical services. To reduce hospital admission rates for parasuicide is probably desirable. While there has been considerable research on parasuicide, it is apparent that many of the findings have limited application to prevention. It is argued that attempts at primary prevention should be directed at those factors in the population considered to have a substantial function in promoting this group of behaviours. The first step in such a program should be the empirical delineation of a typology of parasuicide, since it is not a unitary phenomenon and a single preventive measure is therefore unlikely to have widespread success. Following the recognition of different requirements for different population groups, an experiment in prevention might be attempted by monitoring the parasuicide rates in two closely similar populations, one of which has alterations made sequentially to variables such as the following: the availability of tablets and the form of their presentation; the availability of personal advisory services; and community attitudes to parasuicide. Possible dangers inherent in such experimental epidemiology are acknowledged but it is argued thai aspects of the current approach to the problem of parasuicide may be in need of revision.

The epidemiology of self-poisoning in Hobart, 1968-1972

Continued monitoring of the rates for treated self-poisoning in Hobart over a five year period has revealed a marked increase in this behaviour. Attention is drawn to the load this places on medical and psychiatric services. The present study has shown that the rise in self-poisoning was statistically significant among young males and females of most age-groups. This rise was particularly notable in senior secondary schoolgirls. In terms of geographical distribution, significant increases were observed in the economically depressed central areas of Hobart and in satellite towns. The need for greater emphasis on primary prevention is discussed.

Abuse of drugs "for kicks": a review of 252 admissions

Abuse of drugs "for kicks" is becoming more common in Great Britain. This article reviews 252 consecutive cases of drug abuse admitted to the Regional Poisoning Treatment Centre, Royal Infirmary, Edinburgh, during 1971 and 1972. Of the 189 patients (146 males and 43 females; mean age 20 years) 72% of admissions occurred between 6 p.m. and 8 a.m., and Saturday was the most common day for admissions. The commonest source of referral was via the police or ambulance service. Barbiturates were the drugs most often abused, followed by LSD (lysergide) and Mandrax (methaqualone and diphenhydramine). Sixty-five per cent. of patients had previously abused drugs. Medical care was required in 45% of the admissions. Sixty per cent. were in social class 4 or 5 and psychiatric and social support was required in only a small minority of patients.

The origins of analgesic nephropathy

The association between renal papillary necrosis and prolonged ingestion of compound analgesics containing aspirin and phenacetin, has been widely reported (5, 6, 11, 13, 17, 19, 20, 24, 42). Although formerly thought to occur mainly in Switzerland, Scandinavia and Australia, analgesic nephropathy is now being increasingly reported in Britain (3, 26, 36), and in particular in Western Scotland (33). In the past seven years over 100 cases have been seen in the renal unit of the Western Infirmary, Glasgow, and, of these 42 have died in uraemia.