Risk factors for suicide attempts among alcohol dependent patients

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.

Sex-specific factors associated with lifetime suicide attempt among patients with alcohol use disorders

BACKGROUND

Patients with alcohol use disorder (AUD) are at high risk for suicide attempts. Mental health problems along with AUD-related factors may contribute to this increased risk. Studies have shown sex differences in rates and correlates of suicide attempts.

AIMS

The purpose of the study was to examine mental-health-related and AUD-related factors associated with suicide attempt separately in female and male AUD patients.

METHOD

We collected information about lifetime suicide attempt and mental-health- and AUD-related factors for AUD in-patients (n = 114; 32 females) receiving rehabilitative treatment.

RESULTS

The prevalence of lifetime suicide attempt was 27%, and the rate was similar in both sexes. Among females, current depressive symptoms and current post-traumatic stress disorder diagnosis were associated with suicide attempt. In male AUD patients, among the mental-health-related factors, lifetime major depression, panic disorder, social phobia, childhood sexual abuse and antisocial personality disorder were associated with suicide attempt. In addition, AUD-related factors including longer duration of drinking, history of delirium tremens, greater severity of AUD and lower levels of prolactin were associated with suicide attempt in males.

CONCLUSIONS

Our results indicate that suicide attempts in female AUD patients were more mental-health-related, whereas those in males were also related to the severity of AUD. This suggests that a suicide prevention programme for AUD patients would benefit from a sex-based understanding of the risk factors.

Effectiveness of a Suicide Prevention Module for Adults in Substance Use Disorder Treatment: A Stepped-Wedge Cluster-Randomized Clinical Trial

IMPORTANCE

Individuals with substance use disorders (SUDs) are at high risk for suicide. The Preventing Addiction Related Suicide (PARS) module is the first suicide prevention module developed in and for community substance use intensive outpatient programs (IOPs).

OBJECTIVE

To evaluate the effectiveness of PARS on suicide-related outcomes (ie, knowledge, attitudes, and help-seeking behavior) compared with usual care.

DESIGN, SETTING, AND PARTICIPANTS

This stepped-wedge cluster-randomized clinical trial was conducted from 2017 to 2020, with follow-up assessments conducted after treatment and at 1, 3, and 6 months. Participants included adult outpatients in SUD treatment at community IOPs across western Washington state. Data were analyzed from July 1, 2020, to January 20, 2022.

INTERVENTIONS

The intervention, PARS, was a 1-session secondary prevention module administered by trained SUD counselors consisting of didactic presentations and group discussions about suicide risk factors, warning signs, and actions to take if suicide risk is observed in self or others. The control group received usual care.

MAIN OUTCOMES AND MEASURES

Primary outcomes were suicide knowledge, attitudes about suicide, and help-seeking behavior among patients enrolled in an IOP.

RESULTS

A total of 906 participants (mean [SD] age, 37.5 [12.0] years; 540 [59.6%] men) were included, with 478 participants receiving usual care and 428 participants receiving PARS. In intent-to-treat analysis from baseline to after treatment, there was a greater improvement in suicide knowledge (d = 0.15; 95% CI, 0.08 to 0.23; P < .001) and a greater reduction in maladaptive attitudes (d = 0.18; 95% CI, 0.14 to 0.25; P < .001) for PARS participants compared with those receiving usual care. Improvements were maintained at follow-up for suicide knowledge (1 month: d = 0.16; 95% CI, 0.07 to 0.22; P < .001; 3 months: d = 0.12; 95% CI, 0.05 to 0.19; P = .001; 6 months: d = 0.13; 95% CI, 0.06 to 0.20; P < .001) and reductions in maladaptive attitudes (1 month: d = 0.20; 95% CI, 0.12 to 0.23; P < .001; 3 months: d = 0.10; 95% CI, 0.05 to 0.16; P < .001; 6 months: d = 0.14; 95% CI, 0.09 to 0.19; P < .001), with 788 participants (87.0%) of the sample responding across time points. From baseline to 6 months, there was a greater improvement in help-seeking in the PARS group vs usual care (d = 0.16; 95% CI, 0.01 to 0.32; P = .04).

CONCLUSIONS AND RELEVANCE

This stepped-wedge cluster-randomized clinical trial found that PARS was superior to usual care in improving suicide knowledge, maladaptive attitudes, and help-seeking in adults undergoing community addiction treatment. As a 1-session IOP module developed in partnership with community addiction agencies, PARS has the potential for wide impact in the national suicide prevention strategy.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03166709.

Prevalence and correlates of suicide attempts in high-risk populations: a cross-sectional study among patients receiving opioid agonist therapy in Norway

BACKGROUND

Death by suicide in patients enrolled in opioid agonist therapy (OAT) is a major clinical concern. However, little knowledge exists regarding suicide attempts in this patient group. This study presents the lifetime prevalence of suicide attempts and the associations between suicide attempts and clinical and sociodemographic variables such as education, sex, early onset of substance use (< 13 years of age), substance use patterns, and injecting substance use among patients receiving OAT.

METHODS

We used data from a cohort of OAT patients in Norway obtained from a health assessment of self-reported suicide attempts and sociodemographic and clinical factors. A total of 595 patients receiving OAT were assessed from 2016 to 2020. A binary logistic regression analysis was performed and reported with an unadjusted odds ratio and 95% confidence intervals (OR). The purpose of this assessment was to analyze associations between suicide attempts and substance use patterns as well as the injection of substances during the 30 days leading up to the health assessment. A negative binomial regression analysis with an incidence rate ratio and 95% confidence intervals (IRR) was performed to investigate sex, education, early onset of substance use, and the number of suicide attempts.

RESULTS

Forty-one percent of the OAT patients had attempted to die by suicide at least once during their lifetime. An early onset of substance use was strongly associated with the suicide attempts (IRR: 1.7, 1.3-2.2). No significant association was found between suicide attempts and sex (IRR: 1.2, 0.9-1.6) or education (IRR: 0.6, 0.2-2.1). Likewise, no association was identified between suicide attempts and injecting substance use (OR: 0.9, 0.6-1.3), nor using alcohol (OR: 0.9, 0.7-1.3), amphetamines (OR: 1.0, 0.7-1.3), benzodiazepines (OR: 1.0, 0.7-1.4), cannabis (OR: 1.2, 0.9-1.7), cocaine (OR: 1.3, 0.6-3.0), or opioids (OR: 1.4, 0.9-2.0).

CONCLUSION

The lifetime prevalence of suicide attempts was alarmingly high in the OAT population. An early onset of substance use seemed to be an important risk factor for suicide attempts. There was a non-significant association to more current use of opioids among OAT patients with previous suicide attempts.

Severity of substance use as an indicator of suicide risk among U.S. military veterans

BACKGROUND

Substance use is a strong risk factor for suicidal behavior. To date, however, no known study has evaluated optimal cut-off scores on substance use severity measures to identify individuals who may be at elevated risk for suicide.

METHODS

Data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study, which surveyed a nationally representative sample of 4069 U.S. veterans. Receiver operating characteristic curve analyses were conducted to identify cut-off scores on the Alcohol Use Disorders Identification Test (AUDIT) and Screen of Drug Use (SDU) that optimally differentiated veterans with and without past-year suicidal ideation (SI) in the full sample, as well a high-risk subsample with histories of major depressive disorder (MDD) and/or posttraumatic stress disorder (PTSD).

RESULTS

The prevalence of past-year SI was 11.7% (n = 387); A total of 10.5% (n = 360) of the sample screened positive for past-year alcohol use disorder, 9.1% (n = 314) for past-year drug use disorder, and 22.4% (n = 833) for lifetime MDD/PTSD. The optimal AUDIT cut-off score that differentiated suicide ideators and non-ideators was ≥14 in the full sample, and ≥18 in the high-risk subsample; these scores are indicative of moderate-to-severe alcohol use disorder. The optimal SDU cut-off score was ≥1 for both the full sample and high-risk subsample, which is lower than the recommend cut-off score for probable drug use disorder (≥7).

CONCLUSIONS

Results identify high-specificity thresholds on the AUDIT and SDU that may have clinical utility in suicide risk assessment in veterans. Veterans with moderate-to-severe alcohol use disorder or who use non-prescription drugs may warrant further suicide risk assessment.

Childhood trauma and the prevalence of alcohol dependence in adulthood

Introduction: The experience of trauma and stress in childhood and early adulthood can lead not only to immediate physical and psychological symptoms but also to long-term effects observed in later life.

Aim and method: The objective of the following study was to search for the correlation between the occurrence of childhood trauma and its long-term outcome, that is alcohol dependence, and to review studies concerning the presence of certain personality traits in patients with such trauma experience and prognostic factors for treatment. The literature in the Google Scholar database was reviewed using the following keywords: childhood abuse, childhood trauma, alcohol addiction and alcohol use disorder. The time descriptors 2015-2021 were also used.

Results: On the basis of the conducted studies, it has been found that the experience of extremely stressful situations at a young age is declared by a greater part of the examined patients with alcohol dependence syndrome. It was also noticed that the most significant and most frequently reported negative childhood experiences in patients with alcohol dependence syndrome are physical violence, parental separation or divorce, and mental illness of a family member. It was found that impulsivity, disorder, pessimism, fatigue and asthenia are some of the characteristics of this group of patients.

Conclusions: It can be concluded that there is a significant correlation between the occurrence of traumatic events in childhood and the tendency to develop alcohol addiction in adulthood.

Feasibility and acceptability of safety screening among patients receiving addiction treatment

INTRODUCTION

Premature mortality associated with opioid-related overdose and suicide is a significant public health problem in the United States. Approximately 20-30% of individuals with opioid use disorder (OUD) have a history of both suicide attempt and unintentional opioid overdose. The objective of this study is to evaluate the feasibility of a standardized screen for suicide and overdose among patients receiving addiction treatment.

METHODS

We conducted a cross-sectional study using a convenience sample of patients (n = 113) recruited from two inpatient treatment programs. We used a modified version of the Patient Safety Screener (mPSS) to screen for suicidal ideation, suicide attempt, and overdose. Study staff administered the screen in-person during treatment, and we linked results to administrative clinical data. Subjects (n = 108) and members of their clinical care team (n = 20) completed a screening acceptability survey. We recorded a positive mPSS if a patient reported suicidal ideation in the past two weeks, a suicide attempt, and/or an overdose in the past six months.

RESULTS

Fifty-eight percent of subjects had a positive mPSS screen, and 30.3% reported suicidal ideation, suicide attempt, and overdose. Subjects and clinical staff reported that it was acceptable to screen for suicide attempt(s) and overdose(s). About a third of the clinical staff reported concerns about administration time (n = 7) and impact on workflow (n = 6).

CONCLUSIONS

Both suicide and overdose are important patient safety factors that should be incorporated into addiction treatment and discharge planning. This study's findings support simultaneously screening for suicide and overdose in OUD inpatient treatment settings. Future research needs to determine whether screening improves provision of services and reduces self-injurious behavior.

Self -image and selected clinical variables in the context of childhood abuse in subjects with alcohol dependence

Objective: The objective of the study was to determine the differences in selected clinical variables and self-image in people with alcohol dependence differing in severity of physical, emotional and sexual abuse experienced before age 18.

Method: The study included 90 people with alcohol dependence. The following research tools were used: Early Trauma Inventory (ETI), Adjective Check List (ACL), MAST, SAAD, and a questionnaire designed by the authors. In order to identify groups with varying indices of physical, emotional and sexual childhood abuse, a cluster analysis method was used.

Results: Two groups of subjects with alcohol dependence were identified: Group 1 with high indices of physical, emotional and sexual childhood abuse and Group 2 with low indices. In terms of self-image the subjects in Group 1 compared to subjects in Group 2 were characterized by a lower self-esteem, self-acceptance, resistance to stress, less intense needs for achievement, endurance, order, nurturing others, interaction with opposite-sex partners, subordinations but more intense need for change. The age of alcohol use initiation and the onset of regular alcohol drinking was statistically significantly lower in Group 1. The severity of alcohol dependence was significantly lower in Group 2. The subjects in Group 1 significantly more frequently confirmed the history of a hereditary predisposition to alcohol dependence, suicidal ideation, suicide attempts and self-harm.

Discussion: The obtained results closely correspond to the data available in the literature.

Conclusions: An assessment of exposure to various forms of childhood abuse appears to be an indispensable element of collecting medical history of people with alcohol dependence.

The Role Of Alcohol Use Disorder And Alcohol Consumption In Suicide Attempts-A Secondary Analysis Of 1921 Suicide Attempts

Background

It is not known how characteristics of suicide attempts vary with different forms of alcohol involvement. The aim of this study is to clarify the role of alcohol use disorder and acute alcohol consumption in suicide attempts.

Methods

Data on 1921 suicide attempts was gathered in a major German city over a 5-year period. Suicide attempts were categorised according to a diagnosis of alcohol use disorder and acute alcohol consumption at the time of the attempt. Group comparisons and multinomial logistic regression were used for statistical analysis.

Results

In 331 suicide attempts (17%) an alcohol use disorder was diagnosed. Six hundred and twenty-two suicide attempts (32%) were committed with acute alcohol consumption. Suicide attempts by individuals with alcohol use disorder were more often committed by men, older individuals and as a recurrent attempt, independently of alcohol consumption at the time of the attempt. When alcohol was consumed in suicide attempts by individuals with alcohol use disorder, low-risk methods were used most often.

Conclusions

Individuals with a diagnosis of alcohol use disorder are a high-risk group for multiple suicide attempts and should be a target group for suicide prevention. Screening for suicidality should be a regular part of the clinical assessment in individuals with alcohol use disorder.

Impulsivity and Impulsivity-Related Endophenotypes in Suicidal Patients with Substance Use Disorders: an Exploratory Study

Suicidal behavior (SB) is a major problem in patients with substance use disorders (SUDs). However, little is known about specific SB risk factors in this population, and pathogenetic hypotheses are difficult to disentangle. This study investigated some SB and SUD-related endophenotypes, such as impulsivity, aggression, trait anger, and risk-taking behaviors (RTBs), in forty-eight patients with SUDs in relation to lifetime history of suicide attempts (SAs). Disorders related to alcohol, cannabis, cocaine, opiates, and hallucinogenic drugs were included. Lifetime SAs was significantly associated with both higher impulsivity and higher aggression, but not with trait anger. A higher number of RTBs were associated with lifetime SAs and higher impulsivity, but not with aggression and trait anger. Assessing these endophenotypes could refine clinical SB risk evaluation in SUDs patients by detecting higher-risk subgroups. An important limitation of this study is exiguity of its sample size. Its primary contribution is inclusion of all SUD types.

Addiction and Suicide: A Review

(Reprinted with permission from The American Journal on Addictions 24: 98-104, 2015).

Comparison of selected clinical and personality variables in alcohol–dependent patients with or without a history of suicide attempts

Objective: The aim of the study was to determine differences in the range of socio-demographic variables, selected clinical variables, temperament and character traits, coping with stress strategies and the level of aggression in alcohol addicts with or without a history of suicide attempt(s).

Methods: The study involved 90 people addicted to alcohol, treated in inpatient alcohol dependence treatment program. In order to collect data on socio - demographic variables and selected clinical variables, a self-made questionnaire was used. The severity of alcohol dependence was verified using the MAST and SADD scales. Characteristics of temperament and character were examined with the TCI questionnaire. The BPAQ and COPE questionnaires were used to examine the level of aggression and styles of coping with stress.

Results:Out of 90 subjects with alcohol dependence syndrom, 20% had attempted suicide in the past. The respondents with a history of suicide attempts were statistically significantly younger, were characterized by a younger age of alcohol drinking initiation and the initiation of regular alcohol drinking, and a greater severity of alcohol dependence in the MAST and SADD scales. A significantly larger percentage of respondents who had attempted suicide inflicted self-injury in the past, used other psychoactive substances as well as hypnotics and sedatives. The subjects with a suicide attempt in the interview obtained statistically significantly higher scores in terms of the level of aggression, harm avoidance and self-directedness, and more often used the style of coping with stress based on avoidance and accepting the situation.

Conclusions: The obtained results correspond with data available in the literature and may provide a foundation for theoretical models explaining the phenomenon of suicidal behavior in alcohol addicts as well as for suicide prevention programs in this group of patients.

The possible mediating effect of alcohol dependence on the relationship between adverse childhood experiences and attempted suicide

Adverse childhood experiences (ACEs) and alcohol dependence (AD) carry independent risks for suicidal behavior. While the strength of the association between ACEs and attempted suicide is weakened following adjustment for AD, no study to date has directly been performed to determine whether AD affects the risk of suicide attributable to ACEs. The study aimed to examine the possible role of alcohol dependence (AD) in the relationship between various ACEs and attempted suicide. This cross-sectional study assessed history of ACEs among 184 AD patients and 205 control participants using the Family Health Questionnaire. Lifetime history of attempted suicide was collected using the Chinese version of the Composite International Diagnostic Interview. We used the Sobel test to examine the mediating effects of AD on the relationship between ACEs and attempted suicide. Results showed that the suicide attempters were associated with higher rates of AD and ACEs. The regression analysis showed that AD and multiple ACEs exposure are independently associated with attempted suicide. AD appears as a partial mediator in the relationship between attempted suicide and the specific type of ACE (exposure to a battered mother or sexual abuse) or exposure to ≥3 types of ACEs. We conclude that AD might partially mediate the associations detected between attempted suicide and exposure to a battered mother, sexual abuse, and ≥3 types of ACEs. These observations may provide important insight for intervention strategies aimed at reducing the risk of suicide attempts.

Suicidal ideation and attempts in patients who seek treatment for substance use disorder

Patients with substance dependence have a great risk of suicidal ideation and attempts. The study of the specific risk characteristics of patients with substance use disorders who present with suicidal ideation and/or attempts becomes a crucial clinical issue in order to develop prevention strategies. The main goals of this study were to determine the prevalence rate of both suicidal ideation and attempts among patients receiving treatment for substance use disorder and to analyse the differential characteristics between these patients with and without suicidal behaviours. A sample of 334 patients (263 men-71 women) who sought treatment for substance use disorder in a Spanish clinical centre was assessed. In total, 43.7% of the patients presented with lifetime suicidal ideation (8.7% in the last month) and 17.7% with suicide attempts (1.5% in the last month). Patients with suicidal ideation or attempts showed a more severe addiction profile (assessed by the EuropASI), and more psychopathological symptoms (assessed by the SCL-90-R). Moreover the rate of suicidal ideation and attempts was significantly higher in inpatients than in outpatients. According to these results, systematic screening of suicidal risk in patients seeking treatment for substance use disorders is recommended, especially in those with a greater addiction severity.

Which Psychopathological Syndromes Could Be Associated with the Risk of Suicide among Substance Users?

Background: Research has shown that suicide is a highly present phenomenon among the drug dependent population. Moreover, individuals with substance use disorder (SUD) present high psychopathological comorbidity. This study aimed to describe which clinical syndromes are linked to the presence of risk of suicide. Methods: The study was based on a consecutive non-probabilistic convenience sample of 196 patients who attended the Public Addiction Center in Girona (Spain). Sociodemographic data, as well as suicide risk and drug related characteristics, were recorded. The risk of suicide was assessed with the Spanish version of "risk of suicide". Complicated grief was assessed with the Spanish version of the Inventory of Complicated Grief. Clinical syndromes were measured with the Spanish version of MCMI-III. Results: The syndromes most frequently associated with the presence of risk of suicide were complicated grief, major depression and thought disorder. Conclusions: Different psychopathological syndromes were identified in relation to risk of suicide among patients with SUD. The present results highlight the importance of accurately diagnosing those individuals.

Factors associated with lifetime suicidal ideation and suicide attempts in outpatients with substance use disorders

Risks factors for suicide are multiple and highly prevalent in addicted patients (previous suicide attempts, substance abuse, impulsivity, history of sexual abuse and other factors). The aim of this study is to identify and to compare the clinical and socio-demographic profile of SUD outpatients with lifetime suicidal behavior (previous suicidal ideation and/or suicide attempts) and to analyze the factors related to it. A retrospective cohort study of 696 addicted patients, according to DSM-IV-TR criteria (APA, 2000) were collected from the Addiction Unit of Vall d'Hebron University Hospital. Lifetime suicidal ideation in addicted patients is associated with presence of: borderline personality disorder (BPD), depressive disorders, sexual abuse, polydrug abuse, attention-deficit hyperactivity disorder, and motor impulsivity. The factors associated with suicide attempts were: borderline personality disorder, lifetime abuse (whether emotional, physical or sexual), co-occurrent psychotic disorders, polydrug abuse, anxiety disorders and depressive symptoms. We conclude that previous suicidal ideation and lifetime suicide attempts should be considered in the clinical care of addicted patients. Factors related to both suicidal behaviors share similarities and differences according to our findings and need to be deeply explored in the future.

Suicidal thoughts in persons treated for alcohol dependence: The role of selected demographic and clinical factors

Greater knowledge is needed of potential predictive factors for suicide in cases of alcohol addiction. Therefore, the aim of the study was to identify the socio-demographic variables and clinical factors associated with alcohol dependence which may have an influence on the occurrence of suicidal thoughts in alcohol-dependent patients. A group of 510 patients (396 male and 114 female) diagnosed with alcohol dependence syndrome were interviewed during the third week of therapy according to the Beck Depression Inventory (BDI), the Penn Alcohol Craving Scale (PACS) and the Short Alcohol Dependence Data Questionnaire (SADD). Socio-demographic data was also collected. The results of a binary logistic regression with suicidal thoughts as a dependent variable show that 63 out of the 510 participants (12% of the sample) reported the presence of suicidal thoughts. Alcohol dependence and alcohol craving appear to increase the likelihood of suicidal thoughts, and participants presenting psychiatric disorders were twice as likely to demonstrate suicidal ideation as those who did not. Alcohol dependence, alcohol craving and psychiatric comorbidity may be regarded as risk factors for suicidal ideation in the studied sample, with the only protective factor being living in a relationship.

Investigation of a Suicide Ideation Risk Profile in People With Co-occurring Depression and Substance Use Disorder

Disengagement from services is common before suicide, hence identifying factors at treatment presentation that predict future suicidality is important. This article explores risk profiles for suicidal ideation among treatment seekers with depression and substance misuse. Participants completed assessments at baseline and 6 months. Baseline demographics, psychiatric history, and current symptoms were entered into a decision tree to predict suicidal ideation at follow-up. Sixty-three percent of participants at baseline and 43.5% at follow-up reported suicidal ideation. Baseline ideation most salient when psychiatric illness began before adulthood, increasing the rate of follow-up ideation by 16%. Among those without baseline ideation, dysfunctional attitudes were the most important risk factor, increasing rates of suicidal ideation by 35%. These findings provide evidence of factors beyond initial diagnoses that increase the likelihood of suicidal ideation and are worthy of clinical attention. In particular, providing suicide prevention resources to those with high dysfunctional attitudes may be beneficial.

Suicide Risk Associated with Experience of Violence and Impulsivity in Alcohol Dependent Patients

Alcohol dependence (AD) and aggression-impulsivity are both associated with increased suicide risk. There is a need to evaluate clinical tools in order to improve suicide risk assessment of AD patients. The present study consisted of 95 individuals with a diagnosis of AD, consecutively admitted for addiction treatment, compared with 95 healthy controls. Suicidal risk was assessed together with exposure of violence and impulsivity. AD patients reported significantly higher rates of exposure to violence in childhood, as measured by the Karolinska Interpersonal Violence Scale (KIVS), compared to HC. Within the AD group, individuals with history of suicidal ideation and suicidal behavior reported higher levels of violence experience compared to AD individuals without such history. AD patients with previous suicidal ideation scored higher on self-reported impulsivity as assessed by the Barratt Impulsivity Scale (BIS). Our main finding was that experience of trauma and expression of violent behavior, coupled with increased impulsivity are associated with an elevated suicide risk in AD patients. Future longitudinal studies assessing these traits are needed to evaluate their potential role in identifying AD patients at risk of future suicide.

The co-occurrence of aggression and self-harm: systematic literature review

BACKGROUND

Epidemiological research supports an association between aggression and self-harm through data on the frequency with which individuals exhibit both behaviours. Unbiased evidence, however, is needed to draw conclusions about the nature and extent of co-occurrence.

METHOD

Systematic review of published studies was undertaken to evaluate whether or not the frequency with which aggression and self-harm co-occur is beyond that which would be expected by chance. Outcome measures included: (a) between-group differences on a standardised aggression/self-harm measure - the groups defined by scores on a measure of the other behaviour; (b) correlations between the two behaviours; (c) co-occurrence rates in populations defined by the presence of either behaviour; (d) co-occurrence rates in populations not defined by either behaviour. Odds ratios were calculated for studies presenting complete frequency data.

RESULTS

123 studies, some yielding more than one type of result, met the inclusion criteria. Most case-control studies found elevated levels of aggression in self-harming populations (or self-harm in aggressive populations) compared to controls. The majority of correlational, co-occurrence rate, and odds ratio data found aggression and self-harm to be associated.

LIMITATIONS

Results were subject to descriptive synthesis only and thus, unable to report an overall effect size.

CONCLUSIONS

Evidence suggests that aggression and self-harm frequently co-occur. Such evidence necessitates more theoretical discussion and associated research on the source and nature of co-occurrence. Nonetheless, individuals who present with one behaviour may be considered an 'at-risk' group in terms of exhibiting the other. Such evidence holds implications for practice (e.g. risk assessment).

Addiction and suicide: A review

BACKGROUND

Addiction specialists frequently find themselves faced with suicidal behavior in their addictions patients. Although many addiction treatment programs will not accept clients with recent suicidal behavior, up to 40% of patients seeking treatment for substance dependence report a history of suicide attempt(s).(1-3) Risk factors for suicide have been studied in the general population and among people with mental illness, less is known about risk factors in those with substance use disorders and co-occurring disorders.

METHODS

Studies, psychological autopsies and recent reviews on risk factors for suicide and suicide attempts in patients with alcohol and drug use disorders and the relationship with co-occurring mental illness were examined.

RESULTS AND CONCLUSIONS

Suicidal behavior is a significant problem for people with co-occurring disorders seeking addiction treatment. Several predisposing and precipitating risk factors such as marital and interpersonal relationship disruption, occupational and financial stressors, recent heavy substance use and intoxication as well as a history of previous suicide attempts and sexual abuse combine in an additive fashion with personality traits and mental illnesses to intensify risk for suicidal behavior in addiction patients. Major depression, bipolar disorder, borderline personality disorder and post-traumatic stress disorder are especially associated with suicidal behavior in people with addictive disorders.

DISCUSSION AND SCIENTIFIC SIGNIFICANCE

Treatment implications of these findings are discussed. Addiction treatment providers should routinely gather information about client's suicidal histories, thoughts, and plans in order to assess risk and develop treatment plans for suicidality at various points in treatment.

Alcohol and suicidal behavior: what is known and what can be done

Research on associations between substances of abuse and suicidal behaviors is a large, complex area. Herein, alcohol, the most commonly abused intoxicant worldwide, is examined with a focus on two topics: (1) acute use of alcohol (AUA) shortly prior to suicidal behavior; and (2) more chronic alcohol use disorder (AUD) and suicidal behavior. First, a brief summary of what is known about AUA, AUD, and suicidal behavior is provided. Next, we draw on preliminary evidence, practical considerations, and our own experience to offer recommendations for intervention research that may lower risk associated with AUA and AUD. The literature on AUD and suicidal behavior is more developed, thus we discuss separately research designed to: (1) prevent individuals with AUD with suicidal ideation from engaging in suicidal behavior; and (2) prevent individuals with AUD who have made a suicide attempt from reattempting. Our focus is on clinical intervention strategies for individuals at risk for suicidal behavior that use alcohol or have developed AUD. We also focus on applied research that may directly lead to practical prevention efforts. Although clinical interventions are important components of a comprehensive suicide prevention strategy, they should be complemented with primary prevention efforts.

Levels of aggressiveness are higher among alcohol-related suicides: results from a psychological autopsy study

Suicide is one of the major causes of deaths worldwide. Several studies have showed that alcohol use disorders (AUD) are associated with suicide ideation, suicide attempts, and suicide completion. The majority of the theoretical conceptualization and the bulk of evidence on suicidal behavior and AUD are based on investigations of nonfatal cases because data on nonfatal suicidal behaviors are more readily available. This study aims to explore demographic, clinical, and behavioral dimensions in a large sample of alcohol-related suicides compared to an age-gender matched sample of non-AUD suicides to identify specific factors associated with AUD suicides. We conducted a psychological autopsy study with 158 pairs of AUD and non-AUD suicides. Findings showed that AUD suicides have lower educational level, more biological children and were more likely to be heavy smokers (OR=3.32). Cases were more likely to have family history of alcohol (OR=1.73) and drug abuse (OR=3.61). Subjects had similar prevalences of depressive disorders, anxiety disorders or psychotic disorders. AUD suicides were more likely to meet criteria for current cocaine abuse/dependence (OR=6.64). With respect to personality disorders, AUD suicides presented higher prevalence of Antisocial Personality Disorder (OR=4.68), and were less likely to meet criteria for Avoidant (OR=0.26) and Obsessive-Compulsive Personality Disorders (OR=0.35). Impulsivity scores were higher in AUD suicides (p=0.18), as well as aggression scores (p<0.001). Results form the conditional logistic regression models showed that cocaine abuse/dependence (OR=4.20) and Antisocial Personality Disorder (OR=6.24) were associated with AUD suicide. After controlling for impulsive-aggressive behaviors, levels of aggression were the only psychopathological feature statistically different between AUD and non-AUD suicides (OR=1.28). In conclusion, higher levels of aggressive behaviors are a specific characteristic of AUD suicides. Apart from substance-related diagnoses, AUD and non-AUD suicides have comparable Axis I psychiatric diagnoses and familial transmission of suicidal behavior.

Two HPA axis genes, CRHBP and FKBP5, interact with childhood trauma to increase the risk for suicidal behavior

Childhood trauma is associated with hypothalamic-pituitary-adrenal (HPA) axis dysregulation. Both factors increase risk for suicidal behavior. Corticotropin releasing hormone (CRH) regulates the HPA axis and its actions are moderated by a high-affinity binding protein (CRHBP). We hypothesized that CRHBP variation and interaction with childhood trauma might influence suicidal behavior. Moreover, there might be an additive effect with FKPB5, another HPA axis gene previously associated with suicidality in this dataset. African Americans were recruited: 398 treatment seeking patients with substance dependence (90% men; 120 suicide attempters) and 432 non-substance dependent individuals (40% men; 21 suicide attempters). A total of 474 participants (112 suicide attempters) completed the Childhood Trauma Questionnaire (CTQ). Haplotype-tagging SNPs were genotyped across CRHBP and, for completeness, across CRH, CRHR1 and CRHR2. FKBP5 genotypes were available. Three CRHBP SNPs rs6453267, rs7728378 and rs10474485 showed a nominally significant interaction with the continuous CTQ score to predict suicide attempt; rs7728378 remained significant after FDR correction. There was an additive effect with FKBP5: in the group exposed to high trauma, the prevalence of suicide attempt was 0.35-0.30 in carriers of either the FKBP5 rs3800373 major homozygote or the CRHBP rs7728378 major homozygote and 0.58 in carriers of both major homozygotes. Individuals without either major homozygote were resilient to the effects of childhood trauma (suicide attempt prevalence 0.24). Main effects of CRHBP rs6453267 and CRHR1 rs9900679, both unique to African ancestry, were detected. CRHBP variation may predispose, independently and additively, to suicidal behavior in individuals who have experienced childhood trauma.

Combination of family history of suicidal behavior and childhood trauma may represent correlate of increased suicide risk

BACKGROUND

There is a need to try to identify patients at highest risk for suicidal behavior. A family history of suicidal behavior (FHS) and childhood trauma are two important risk factors for suicidal behavior. It was therefore decided to combine them and examine if the combination would identify patients at even increased risk for suicidal behavior.

METHODS

Two hundred and eighty one substance dependent patients with a FHS completed the Childhood Trauma Questionnaire (CTQ) and were interviewed about their lifetime history of suicidal behavior. Patients with the combination of a FHS and CTQ score above the mean were examined and compared with FHS patients with a CTQ score below the mean.

RESULTS

One hundred and two of the 129 (79.1%) FHS patients with a CTQ score above the mean had attempted suicide. Thirty five of the 40 female (87.5%) FHS patients with a CTQ score above the mean had attempted suicide .Patients with a CTQ score above the mean were found significantly more among FHS patients who had attempted suicide than among FHS patients who had never attempted. FHS attempters with a CTQ score above the mean had a significantly earlier age of first attempting and had made more attempts than FHS attempters with a CTQ score below the mean.

LIMITATIONS

Childhood trauma data derived from self-report questionnaire. No consistent collateral information about FHS.

CONCLUSION

The combination of a FHS and childhood trauma may represent a correlate of increased risk of attempting suicide, attempting earlier, and making more attempts.

Test of a clinical model of drinking and suicidal risk

BACKGROUND

There are few data on the role of drinking patterns in suicidal thoughts or behavior among alcohol-dependent individuals (ADIs) and meager data on variables that may influence the role of drinking in suicidal thoughts and behavior. This study tested a heuristic model that predicts that drinking promotes suicidal thoughts and behavior, the association is mediated (accounted for) by depressive symptoms, and that anger moderates (increases) the risk associated with intense drinking.

METHODS

Data from Project MATCH, a multisite alcohol use disorders treatment trial, were analyzed using structural equation modeling. There were 1,726 participants including 24% women and a mean age of 40.2 ± 11.0 years. Subjects were assessed at baseline and at 3-, 9-, and 15-month follow-up. Two categorical measures (presence/absence) of suicidal ideation (SI) were used that were analyzed in separate models. Predictors of interest were continuous assessments of average drinking intensity (i.e., drinks per drinking day or DDD), drinking frequency (i.e., percent days abstinent or PDA), depression, and anger.

RESULTS

Both DDD and PDA were associated with SI at a statistically significant level, with PDA showing an inverse association. Depression scores served as a partial mediator or a full mediator of the drinking-SI relationship depending on the measure of SI used in the analysis. The models testing anger scores as a moderator fit the data poorly and did not support that anger serves as a moderator of the drinking-SI association.

CONCLUSIONS

Greater drinking intensity and drinking frequency predict SI among ADIs and depression serves as a mediator of these associations, but anger does not appear to serve as a moderator. Further research is required to clarify whether depression serves as a partial or full mediator and to see whether the results herein extend to suicidal behavior (i.e., suicide attempt, suicide).

Cardiovascular Diseases among Suiciders: A Population-Based Study in Northern Finland Population

Objective. Depression has been found to be an independent risk factor with cardiovascular diseases (CVDs) and also associated with increased mortality among these patients. Method. We used a comprehensive database of all suicides (n = 2, 283) committed in Northern Finland with information on all hospital-treated cardiovascular diseases and psychiatric disorders. Results. Coronary artery disease (CAD) had been present in 7.7% and other cardiovascular diseases (CVDs) in 11.6% of the suiciders. The likelihood of suicide for patients with hospital-treated CAD was estimated to be two-fold compared to the general population while likelihood for suicide was not elevated among those with other CVDs. Males with CAD and females with CAD or any CVD had been hospitalized significantly more often with depression compared to reference group. Conclusions. Suicidality among patients with cardiovascular diseases has been suggested to associate with depression. Psychiatric consultation is highly recommended in clinical practice for cardiac patients with depression or alcohol-related disorders.

Interaction of FKBP5, a stress-related gene, with childhood trauma increases the risk for attempting suicide

Childhood trauma is associated with hypothalamic-pituitary-adrenal (HPA) axis dysregulation and is a known risk factor for suicidal behavior. In this study we sought to determine whether the impact of childhood trauma on suicide risk might be modified by FKBP5, an HPA-axis regulating gene. Sixteen FKBP5 haplotype-tagging single nucleotide polymorphisms (SNPs) were genotyped in a sample of African Americans: 398 treatment-seeking patients with substance dependence (90% men; 120 suicide attempters) and 432 nonsubstance-dependent individuals (40% men; 21 suicide attempters). In all, 474 participants (112 suicide attempters) also completed the Childhood Trauma Questionnaire (CTQ). Primary haplotype analyses were conducted with the four SNPs implicated in earlier studies: rs3800373, rs9296158, rs1360780, and rs9470080. We found that childhood trauma was associated with suicide attempt (P<0.0001). Although there was no main effect of the two major yin yang haplotypes in the four SNP haplotype blocks, there was a haplotype influence on suicide risk (p=0.006) only in individuals exposed to high levels of childhood trauma. In this group, 51% with two copies of the risk haplotype, 36% with one copy, and 20% with no copies had attempted suicide. The total logistic regression model accounted for 13% of the variance in attempted suicide. Analyses of the 16 SNPs showed significant main effects on suicide attempt of rs3777747, rs4713902, and rs9470080 and interactive effects of rs3800373, rs9296158, and rs1360780 with CTQ score on suicide attempt. These data suggest that childhood trauma and variants of the FKBP5 gene may interact to increase the risk for attempting suicide.

Factors Associated with the History of Attempted Suicide

Background: The present study examines a population of criminal justice clients for suspected substance-related problems. Aims: It aims to identify variables associated with a history of suicide attempt (SA). Method: 6,836 clients were interviewed with the Addiction Severity Index (ASI). Attempters were compared to nonattempters regarding substance use, medical/psychiatric status, family history, and social relationships in a stepwise forward logistic regression. Results: Attempters (21%) were more likely to report binge drinking, intake of illicit drugs, injection of drugs, physical and mental illness, problematic family history, and history of being abused. After logistic regression, SA was independently associated with older age, female gender, binge drinking, delirium tremens, injection, overdose, medical problems, psychiatric symptoms, family history of alcohol or psychiatric problems, and sexual, physical, and emotional abuse. The psychiatric and family/social domains (including being abused) most strongly separated attempters from nonattempters. Conclusions: Family background factors, psychiatric symptoms, severity of substance use, and sexual, physical, and emotional abuse appear to be factors associated with SA among criminal justice clients.

Suicidal behaviors in surviving monozygotic and dizygotic co-twins: is the nature of the co-twin's cause of death a factor?

Genetically informative samples can address hereditary and experiential influences on suicide-related behaviors. The frequency of suicide-related behaviors was compared in twins from two survivor groups: (1) those whose co-twins' deaths were suicides (monozygotic [MZ]: n = 47; dizygotic [DZ]: n = 31), and (2) those whose co-twins' deaths were nonsuicides (MZ: n = 347; DZ: n = 170). The frequency of suicide attempts among suicide survivors was significantly higher in MZ than DZ twins, while the frequency of suicide attempts among nonsuicide twin survivors did not differ between MZ and DZ twins. Twin concordance for suicide attempts more likely reflects a genetic predisposition than a behavioral reaction to the loss.

What are the needs of alcohol dependent patients with a history of sexual violence? A case-register study in a metropolitan region

BACKGROUND

Sexual violence has become increasingly apparent as a factor determining more complex treatment needs in patients with substance abuse. However, empirical evidence on specific patterns of differences between patients with and without a history of sexual violence is scarce.

METHODS

Our sample consisted of alcohol dependent outpatients treated during a two-year period in a German metropolitan region. The analysis was based on a local case register and included all patients for whom information on lifetime sexual violence was available (N=1981; 33.4% female). In a case-control design, patients with a history of sexual violence were compared to patients without such experiences regarding a wide range of clinical and social factors indicative of potential needs.

RESULTS

More than 35% of the female patients and 6% of the male patients reported a history of sexual violence. Victims differed from non-victims across a variety of domains, including psychiatric symptoms and suicide attempts, legal problems, financial and family problems, previous use of services, and need for additional services during the current treatment. Patient gender emerged as a significant moderator of several of these associations.

CONCLUSIONS

The findings indicate that an effort needs to be made to link addiction treatment, other parts of the health care system, and further institutions, such as family services and parts of the legal system, so that the complex needs of this vulnerable population can be met in an adequate way.

Association between childhood trauma and aggression in male prisoners

Childhood trauma and aggression were examined in 540 male prisoners. The Thus 540 male prisoners had a psychiatric interview, completed the Childhood Trauma Questionnaire (CTQ), and were assessed with the Brown-Goodwin Lifetime History of Aggression (BGHA) interview. There were significant correlations between CTQ scores and BGHA scores. Also prisoners with CTQ scores above the median had significantly higher BGHA scores than prisoners with CTQ scores below the median. Significantly more of the prisoners with CTQ scores above the median had more than one conviction, and significantly more had convictions as minors, and had exhibited violent behavior in prison. However, in logistic regression analyses that included possible confounding variables, CTQ scores related only to violence in prison while BGHA scores related to violent crime, having more than one conviction, conviction as a minor, and violence in prison. The relationship between CTQ and BGHA scores suggests the possibility that childhood trauma may be one determinant of aggression in prisoners.

Characteristics of cocaine dependent patients who attempt suicide

There have been few studies examining risk factors for attempting suicide among cocaine dependent patients. Therefore, a large group of 406 abstinent cocaine dependent patients had a psychiatric interview and completed the Childhood Trauma Questionnaire. Patients who had or had never attempted suicide were compared on putative suicide risk factors. The results showed that 43.5% of the patients had attempted suicide. Attempters were younger; more were female; more reported childhood trauma, a family history of suicidal behavior, a history of aggression, treatment with antidepressant medication, and comorbidity with alcohol and opiate dependence. Logistic regression revealed that childhood physical abuse, childhood emotional negelect, comorbidity with alcohol dependence, and treatment with antidepressant medication were significant predictors of attempting suicide. Thus these results suggest that attempting suicide is common among cocaine dependent patients and that both distal and proximal risk factors may play a role.

Predicting inpatient suicides and suicide attempts by using clinical routine data?

OBJECTIVE

The study aimed at exploring prevalence and risk factors of inpatient suicides and attempted suicides in a psychiatric hospital.

METHOD

Based on the German psychiatric basic documentation system, 20,543 patients with 40,451 episodes of inpatient care (1995-2004) in a psychiatric state hospital were included. Besides univariate analyses, multivariate logistic regression analyses and classification and regression tree analyses were performed.

RESULTS

Forty-one inpatient suicides were recorded. Risk of inpatient suicide is increased for patients with resistance to psychopharmacological treatment, previous suicide attempt, severe side effects and supportive psychotherapy before admission. Two hundred fourteen inpatient suicide attempts occurred during the 10-year period. Risk factors of inpatient suicide attempt are assault, personality disorder, previous suicide attempt, psychopharmacological treatment resistance, suicidal thoughts at admission, schizophrenia, depression, female sex and length of stay.

CONCLUSION

The identified risk factors underline the need for a cautious investigation of previous suicide attempts as well as for giving special attention to patients who have problems with psychopharmacotherapy during hospitalization.