The Association of Alcohol Use Disorders with Suicidal Ideation and Suicide Attempts in a Population-Based Sample with Mood Symptoms

Investigating Associations of Substance Use and Dependence With Planned Versus Unplanned Suicide Attempt

OBJECTIVE

The present analyses investigated substance use and dependence as correlates of past-year suicide attempt and of unplanned versus planned suicide attempt in a nationally representative sample.

METHOD

Participants were 214,505 adults (52% female; 64% White, 12% Black, <1% Native American, <1% Pacific Islander, 6% Asian, 16% Hispanic, 2% multiracial) from the 2015-2019 National Surveys on Drug Use and Health. Four logistic regression models were constructed. Models 1 and 2 examined substance use and dependence, respectively, as correlates of suicide attempt. Models 3 and 4 evaluated whether substance use and dependence were related to suicide attempt in the absence of a plan.

RESULTS

In Models 1 and 2, higher cigarette smoking and marijuana use; any use of opioids, sedatives, and hallucinogens; and greater dependence on nicotine, alcohol, marijuana, and any illicit or prescription drug were associated with elevated risk for suicide attempt. Associations with cigarette smoking, sedative use, and dependence on nicotine, alcohol, and any illicit or prescription drug remained statistically significant in sensitivity analyses limited to individuals with suicidal ideation. In Models 3 and 4, substance use and dependence were unrelated to risk for unplanned (vs. planned) suicide attempt.

CONCLUSIONS

Although substance-related outcomes are consistently associated with suicide attempt, there was little evidence that substance use and dependence are related to risk for unplanned versus planned suicidal behavior.

Could reasons for admission help to screen unhealthy alcohol use in emergency departments? A multicenter French study

Background

Many patients admitted to general emergency departments (EDs) have a pattern of drinking that could lead to future alcohol-related complications. However, it is often difficult to screen these patients in the context of emergency. The aim of this study is to analyze whether reasons for admission could help to screen patients who have an unhealthy alcohol use.

Method

Patients were recruited among six public hospital ED in France, between 2012 and 2014. During a one-month period in each hospital, anonymous questionnaires including sociodemographic questions, AUDIT-C and RAPS4-QF were administered to each patients visiting the ED. The reason for admission of each patient was noted at the end of their questionnaire by the ED practitioner.

Results

Ten thousand Four hundred twenty-one patients were included in the analysis. Patients who came to the ED for injuries and mental disorders were more likely to report unhealthy alcohol use than non-harmful use or no use. Among male patients under 65 years old admitted to the ED for a mental disorder, 24.2% drank more than four drinks (40 g ethanol) in typical day at least four time a week in the last 12 months. Among these patients, 79.7% reported daily or almost daily heavy episodic drinking (HED, 60 g ethanol), and all were positive on the RAPS4-QF.

Conclusion

This study highlights that unhealthy alcohol use is frequent among ED patients and particularly among those who come for injuries or mental disorders. Men under 65 years old with a mental disorder require special attention because of their increased prevalence of daily or almost daily HED.

Suicidal behavior across a broad range of psychiatric disorders

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

A high sense of coherence can mitigate suicidal ideation associated with insomnia

BACKGROUND

The present study aimed to investigate whether insomnia is associated with suicidal ideation (SI) among Japanese workers by conducting a multi-level analysis with sense of coherence (SOC) as a random effect.

PARTICIPANTS AND PROCEDURE

A cross-sectional survey was conducted among 19,481 workers in Tsukuba, Japan. Data from 7,175 participants aged 20-65 years were included in the analysis. The Athens Insomnia Scale (AIS) was used as the independent variable, and SI over the past year was used as the dependent variable. SOC was measured using the five-point SOC-13 scale, and socioeconomic and health factors were investigated as covariates. Participants were divided into three groups (low, medium, and high) based on their SOC scores. Multilevel logistic regression analysis was performed to calculate odds ratios (OR) and 95% confidence intervals (95% CI).

RESULTS

In the high-SOC group, only one person had SI. In a multi-level logistic analysis that excluded the high SOC group, insomnia was found to be associated with SI (OR = 2.26, 95% CI [1.75, 2.93]). Furthermore, the AIS sub-items "Final awakening earlier than desired" (OR = 1.26, 95% CI [1.05, 1.50]) and "Sense of well-being during the day" (OR = 1.63, 95% CI [1.34, 1.99]) were associated with SI. 8.95% or 11% of the variation in the presence or absence of SI was found to be explained by differences between SOC groups.

CONCLUSIONS

The study highlights that insomnia is associated with SI, and that high SOC may reduce SI even under insomnia. Future longitudinal studies are needed to confirm whether high SOC reduces SI due to insomnia.

Shared genetic liability for alcohol consumption, alcohol problems, and suicide attempt: Evaluating the role of impulsivity

Heavy drinking and diagnosis with alcohol use disorder (AUD) are consistently associated with risk for suicide attempt (SA). Though the shared genetic architecture among alcohol consumption and problems (ACP) and SA remains largely uncharacterized, impulsivity has been proposed as a heritable, intermediate phenotype for both alcohol problems and suicidal behavior. The present study investigated the extent to which shared liability for ACP and SA is genetically related to five dimensions of impulsivity. Analyses incorporated summary statistics from genome-wide association studies of alcohol consumption (N = 160,824), problems (N = 160,824), and dependence (N = 46,568), alcoholic drinks per week (N = 537,349), suicide attempt (N = 513,497), impulsivity (N = 22,861), and extraversion (N = 63,030). We used genomic structural equation modeling (Genomic SEM) to, first, estimate a common factor model with alcohol consumption, problems, and dependence, drinks per week, and SA included as indicators. Next, we evaluated the correlations between this common genetic factor and five factors representing genetic liability to negative urgency, positive urgency, lack of premeditation, sensation-seeking, and lack of perseverance. Common genetic liability to ACP and SA was significantly correlated with all five impulsive personality traits examined (rs = 0.24-0.53, ps < 0.002), and the largest correlation was with lack of premeditation, though supplementary analyses suggested that these findings were potentially more strongly influenced by ACP than SA. These analyses have potential implications for screening and prevention: Impulsivity can be comprehensively assessed in childhood, whereas heavy drinking and suicide attempt are quite rare prior to adolescence. Our findings provide preliminary evidence that features of impulsivity may serve as early indicators of genetic risk for alcohol problems and suicidality.

Risk Factors Associated With Peripartum Suicide Attempts in Japan

IMPORTANCE

Peripartum suicide attempt is a major psychiatric complication associated with pregnancy, but the risk factors remain largely uncertain.

OBJECTIVE

To identify the demographic characteristics and predisposing risks for peripartum suicide attempts and postpartum depression.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used retrospective data on pregnant women who delivered children between April 1, 2016, and March 31, 2021, at 712 hospitals in Japan. The nationwide Diagnosis Procedure Combination database was used.

EXPOSURES

Psychiatric and nonpsychiatric medical history, age, alcohol and tobacco use, and obstetric complications and procedures.

MAIN OUTCOMES AND MEASURES

Data on admissions for prepartum suicide attempt and delivery during the same hospital stay and readmissions for depression or suicide attempt within 1 year post partum were collected. Comparisons of prevalence of each study variable were performed, and multivariable logistic regression analyses were used to determine risk factors.

RESULTS

From a total of 39 908 649 hospitalization episodes, 804 617 cumulative pregnant women (median [IQR] age at childbirth, 33 [29-36] years) who delivered at the enrolled hospitals were identified, including 1202 who were admitted for suicide attempt and delivery during the same hospital stay and 111 readmitted for suicide attempt within 1 year post partum. Risk factors associated with prepartum suicide attempts included younger age (adjusted odds ratio [aOR], 0.99; 95% CI, 0.98-1.00) and histories of personality disorder (aOR, 10.81; 95% CI, 5.70-20.49), depression (aOR, 3.97; 95% CI, 2.35-6.70), schizophrenia (aOR, 2.89; 95% CI, 1.52-5.50), and adjustment disorder (aOR, 2.66; 95% CI, 1.07-6.58). Risk factors associated with postpartum suicide attempts included younger age (aOR, 0.96; 95% CI, 0.93-1.00), heavy tobacco use (aOR, 23.09; 95% CI, 5.46-97.62), and histories of alcohol use disorder (aOR, 163.54; 95% CI, 28.30-944.95), personality disorder (aOR, 10.28; 95% CI, 3.29-32.10), anxiety disorders (aOR, 8.13; 95% CI, 2.88-22.98), depression (aOR, 7.27; 95% CI, 2.95-17.91), schizophrenia (aOR, 5.77; 95% CI, 2.17-15.38), bipolar disorder (aOR, 3.98; 95% CI, 1.36-11.67), and insomnia (aOR, 3.17; 95% CI, 1.30-7.78). On sensitivity analysis, risk factors associated with postpartum depression after excluding those with prenatal depression included histories of personality disorder, adjustment disorder, bipolar disorder, insomnia, and anxiety disorders.

CONCLUSIONS AND RELEVANCE

The findings of this cohort study suggest that histories of smoking and prenatal psychiatric disorders are potential risk factors for peripartum suicide attempts and may require additional treatment and prevention interventions.

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.

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.

Sibling alcohol use disorder is associated with increased risk for suicide attempt

The association between having a sibling diagnosed with alcohol use disorder (AUD) and risk for suicide attempt may be attributable to shared genetic liability between AUD and suicidal behavior, effects of environmental exposure to a sibling's AUD, or both. To distinguish between these alternatives, we conducted a series of Cox regression models using data derived from Swedish population-based registers with national coverage. Among full sibling pairs (656,807 males and 607,096 females), we found that proband risk for suicide attempt was significantly elevated when their sibling was affected by AUD, even after accounting for the proband's AUD status. Further, risk for proband suicide attempt was consistently higher when the sibling's AUD registration had occurred more recently. Our findings provide evidence for exposure to sibling AUD as an environmental risk factor for suicide attempt and suggest that clinical outreach may be warranted following a sibling's diagnosis with AUD.

Impulsivity Scale-12 and its utilization in alcohol use disorder

INTRODUCTION

One of the core symptoms of alcohol use disorder (AUD) is impulsivity. The recently published study on the Impulsivity Scale 12 (IS-12) offers a promising tool to use in clinics working with clients with AUD due to its simplicity. IS-12 includes subscales related tocognitive impulsivity and behavioral impulsivity, which are related to different aspects of AUD symptomatology. The aim of the study was to adapt IS-12 to polish and test its utility in a sample of patients diagnosed with AUD.

METHODS

Using a Confirmatory Factor Analysis, we compared the two-factor model of the Polish adaptation of the BIS-11 and the IS-12 on a sample of 615 patients diagnosed with AUD. Additionally, we explored the association between the IS-12's cognitive impulsivity and behavioral impulsivity subscales and depressive symptoms, AUD severity, and suicidal ideation using Structural Equation Modeling on a subsample of 450 patients with AUD.

RESULTS

The IS-12 demonstrated a better model fit and good reliability compared to the BIS-11. Moreover, cognitive impulsivity predicted suicidal ideation, but not AUD severity, while behavioral impulsivity predicted AUD severity, but not suicidal ideation. Both subscales of IS-12 predicted depressive symptoms.

CONCLUSION

Consistent with prior work, findings indicate that the second-order factor model of the BIS-11 had reliability issues and evidenced poor model fit. In contrast, the IS-12 demonstrated a satisfactory model fit and was predictive of clinical symptomatology. Thus, utilizing an easy tool, such as IS-12, might be beneficial for researchers and clinicians working with patients with AUD.

Association Between Patterns of Alcohol Use and Short-Term Risk of Suicide Attempt Among Patients With and Without Reported Suicidal Ideation

OBJECTIVE

To evaluate the association between patterns of alcohol use and short-term risk of suicide attempt among patients with and without reported suicidal ideation.

METHODS

Kaiser Permanente Washington electronic health record data were used to identify mental health visits (1/1/2010-6/30/2015) with documented assessments for unhealthy alcohol use (AUDIT-C) and suicidal ideation (PHQ-9 ninth question). Logistic regression fit using generalized estimating equations were used to conduct visit-level analyses, accounting for correlation between individuals' assessments. Separate models evaluated the association between (1) level of alcohol consumption and (2) frequency of heavy episodic drinking (HED), in combination with suicidal ideation (any vs none), with suicide attempt within 90 days following each visit. Primary models adjusted for age, gender, race/ethnicity and visit year.

RESULTS

Of 59,705 visits (43,706 unique patients), 372 (0.62%) were followed by a suicide attempt within 90 days. The risk of suicide attempt was significantly higher for patients reporting suicidal ideation across all levels of alcohol consumption compared to patients reporting low-level alcohol use and no suicidal ideation, particularly high-level use (OR 9.77, 95% CI, 6.23-15.34). Similarly, risk of suicide attempt was higher for patients reporting suicidal ideation across all levels of HED relative to those reporting no HED or suicidal ideation, particularly HED monthly or more (OR 6.80, 95% CI 4.77-9.72). Among patients reporting no suicidal ideation, no associations were observed.

CONCLUSIONS

Findings underscore the potential value of offering alcohol-related care to patient reporting suicidal ideation. Additional strategies are needed to identify suicide risk among those reporting no suicidal ideation.

Health Behavior Differences Between Male and Female U.S. Military Personnel by Sexual Orientation: The Importance of Disaggregating Lesbian, Gay, and Bisexual Groups

INTRODUCTION

The aims of the study are to identify health-related behaviors associated with sexual orientation among active duty military personnel and to compare those behaviors when lesbian, gay, and bisexual (LGB) groups are aggregated and disaggregated.

MATERIALS AND METHODS

We used public data from the 2015 Health-Related Behavior Survey of Active Duty Military Personnel. Binomial logistic regression analyses were used to examine differences between and within heterosexual, same-sex, and bisexual groups as predicted by the following correlates: demographic characteristics, physical activity, substance use, probable mood disorders, unwanted sexual contact, physical abuse, suicidal behaviors, and sexually transmitted infection (STI).

RESULTS

In univariate analyses, rates of lifetime unwanted sexual contact and lifetime suicidal ideation were significantly higher for bisexual females compared to other groups. The results of regression analyses differed depending on whether LGB groups were aggregated or disaggregated. Aggregated LGB versus heterosexual model found significant differences with respect to unwanted sexual contact, lifetime suicide attempt, STI, smoking, and marijuana use. Disaggregated models found different patterns of significant correlates, e.g., correlates comparing gays to heterosexual males were STI, sexual contact, lifetime suicide attempt, and age; correlates comparing lesbians to heterosexual females were heavy drinking, probable post-traumatic stress disorder, ever used marijuana, lifetime suicide attempt, lifetime physical abuse, and smoking.

CONCLUSION

The findings are consistent with those of previous research showing highest risk for suicidal behaviors and substance abuse among bisexual individuals. We recommend that future studies and clinical care consider LGB sexual identities as heterogeneous groups; otherwise, risks for adverse health behaviors may be overlooked.

Short-term risk of suicide attempt associated with patterns of patient-reported alcohol use determined by routine AUDIT-C among adults receiving mental healthcare

OBJECTIVE

To evaluate the association between alcohol use routinely reported during outpatient mental healthcare visits and short-term risk of subsequent suicide attempt.

METHODS

Using a longitudinal retrospective-cohort design, electronic health records identified adult outpatient visits to a mental health provider (1/1/2010-6/30/2015) at Kaiser Permanente Washington with a documented Alcohol Use Disorders Identification Test-Consumption [AUDIT-C]. Suicide attempts within 90 days of AUDIT-C documentation were defined using death certificate cause-of-death and diagnosis codes (non-lethal). Visit-level analyses used generalized estimating equations to account for correlation between multiple AUDIT-Cs for individuals. Separate models evaluated the association between (1) level of consumption and (2) frequency of heavy drinking episodes and suicide attempts, adjusted for visit year, demographics, depressive symptom, and suicidal ideation.

RESULTS

Of 59,382 patient visits, 0.62% (N = 371) were followed by a suicide attempt within 90 days. Patients reporting high-level alcohol use were 1.77 times (95% CI, 1.22-2.57) more likely to attempt suicide than those reporting low-level use. Patients reporting daily or almost daily heavy drinking episodes were 2.33 times (95% CI, 1.38-3.93) more likely to attempt suicide than those reporting none.

CONCLUSIONS AND RELEVANCE

The AUDIT-C is a valuable tool for assessing patterns of patient-reported alcohol use associated with subsequent suicide attempt.

Clinical Correlates of Alcohol Use Disorder in Depressed Patients with Unipolar and Bipolar Disorder

OBJECTIVE

Alcohol use disorder (AUD) is one of the most frequent comorbid conditions in mood disorders. We aimed to examine the relationships between clinical phenotypes of acutely depressed subjects and co-occurring AUD.

METHODS

Clinical assessment including diagnosis of mood disorder and co-occurring AUD, the severity of depressive or manic symptoms, and affective temperaments were conducted in 137 subjects suffering from a major depressive episode. According to the presence of AUD, clinical variables were compared between the two groups. Using binary logistic regression models, the effects of mood symptoms and affective temperaments on the risk of AUD were determined.

RESULTS

Severity of manic symptoms, suicidal ideation, and childhood trauma were higher in the AUD group than in the non-AUD group. Scores for irritable and hyperthymic temperament were higher and the score for anxious temperament was lower in the AUD group. In regression models adjusting confounders, anxious temperament was an independent protector against AUD. On the other hand, the diagnosis of bipolar disorder and the irritable manic symptom dimension increased the risk of AUD.

CONCLUSION

Anxious temperament decreased the AUD risk, whereas irritable manic symptoms increased the risk during depression. AUD in mood disorders may be an expression of manic psychopathology.

Gender variations in the relationship between social capital and mental health outcomes among the Indigenous populations of Canada

Background

In this paper we examine the relationship between social capital and two mental health outcomes—self-rated mental health (SRMH) and heavy episodic drinking (HED)—among the Indigenous populations of Canada. We operationalize a unique definition of social capital from Indigenous specific sources that allows for an analysis of the importance of access to Indigenous networks and communities. We also examine gender variations in the relationship between social capital and the two outcomes, as there is a noticeable lack of research examining the influence of gender in the recent literature on the mental health of Indigenous populations in Canada.

Methods

Using data from the 2012 cycle of the Aboriginal Peoples Survey, logistic regression models were estimated to assess if gender was a significant predictor of either SRMH or HED among the entire Indigenous sample. The sample was then stratified by gender and the relationship between two social capital variables—one general and one indigenous-specific—and each mental health outcome was assessed separately among male and female respondents. All analyses were also further stratified into specific Indigenous groups—First Nations, Métis, or Inuit—to account for the unique cultures, histories, and socioeconomic positions of the three populations.

Results

Female respondents were more likely to report fair or poor SRMH in the total sample as well as the First Nations and Métis subsamples (OR = 1.48, CI = 1.14–1.91; OR = 1.63, CI = 1.12–2.36; OR = 1.44, CI = 1.01–2.05 respectively). However, female respondents were less likely than males to engage in weekly HED in all three of the same populations (OR = 0.43, CI = 0.35–0.54, all respondents; OR = 0.42, CI = 0.31–0.58, First nations; OR = 0.39, CI = 0.27–0.56, Métis). Social capital from sources specific to Indigenous communities was associated with lower odds of weekly HED, but only among Indigenous men. Meanwhile the strength of family ties was associated with lower odds of reporting fair/poor SRMH among both Indigenous men and women. However, these results vary in strength and significance among the different Indigenous populations of Canada.

Conclusions

The results of this paper address a critical gap in the literature on gender differences in SRMH and HED among the Indigenous populations of Canada, and reveal gendered variations in the relationship between social capital and SRMH and HED. These findings support further investigation into the role that social capital and particularly Indigenous-specific forms of social capital may play as a determinant of health. This research could contribute to future mental health initiatives aimed at strengthening the social capital of Indigenous populations and promoting resilient Indigenous communities with strong social connections.

Familial Aggregation and Coaggregation of Suicide Attempts and Comorbid Mental Disorders in Adults

IMPORTANCE

Clarification of the joint influence of familial patterns of suicide attempts and comorbid mental disorders can enhance the understanding and prevention of suicide attempts.

OBJECTIVE

To investigate the familial patterns of suicide attempts and comorbid mental disorders and their associations in a 2-site family study of mood and anxiety disorders.

DESIGN, SETTING, AND PARTICIPANTS

Data were obtained from 2 parallel community-based family studies conducted in the United States (National Institute of Mental Health [NIMH] study) and in Lausanne, Switzerland (PsyCoLaus study), on the comorbidity of mood and anxiety disorders. The study sample comprised 1119 adult probands and 5355 first-degree relatives. Data were collected and analyzed from October 2004 to December 2016.

MAIN OUTCOMES AND MEASURES

Lifetime suicide attempt and mental disorders in first-degree relatives, obtained through direct interviews or family history reports.

RESULTS

The study included 1119 adult probands (675 female [60.3%] and a mean [SD] age of 50 [12.0] years) and 5355 first-degree relatives (2752 female [51.4%] and a mean [SD] age of 52 [1.5] years). Of these participants, 90 (8.0%) of 1119 probands and 199 (3.7%) of 5355 relatives had a lifetime history of suicide attempt. Those with such a history had higher rates of all mental disorders, a greater number of disorders, and statistically significantly poorer current and lifetime global functioning. After adjustment for age and sex, a statistically significant association between suicide attempts in probands and in relatives was found at the NIMH site (OR, 2.6; 95% CI, 1.5-4.7), at the Lausanne site (OR, 3.1; 95% CI, 1.6-6.0), and in the combined data (OR, 2.9; 95% CI, 1.9-4.5). All mood disorder subtypes and substance use disorders were statistically significantly associated with suicide attempts. The familial association between lifetime suicide attempts in probands and relatives was not statistically significant for the combined sample (OR, 1.6; 95% CI, 1.0-2.7) after adjustment for comorbid conditions in probands and relatives. Social anxiety disorder in probands was associated with suicide attempts in relatives (OR, 2.4; 95% CI, 1.7-3.5) after controlling for comorbid mood, anxiety, and substance use disorders.

CONCLUSIONS AND RELEVANCE

Familiality of suicide attempts appears to be explained by a history of mental disorders among those with suicide attempts; the novel finding of a common familial diathesis for suicide attempts and social anxiety, particularly in combination with mood disorders, has heuristic value for future research and may be a risk marker that can inform prevention efforts.

Depressive symptoms and age of alcohol use onset interact to predict suicidal ideation

Distal risk factors of alcohol use may increase suicidal ideation in the presence of proximal risk factors, such as depressive symptoms. We tested whether depressive symptoms and age at onset of alcohol use interact to predict suicidal ideation in 500 individuals (67% men; 68% Black/African American) under criminal justice supervision. Regression analysis revealed that age of onset negatively associated with suicidal ideation only at average and high levels of depressive symptoms while controlling for suicide attempt history. Clinicians may consider individuals with an early age of onset of alcohol use and current depressive symptoms at risk for suicidal ideation.

Insomnia treatment in the context of alcohol use disorder: A systematic review and meta-analysis

PURPOSE

To determine the efficacy of behavioral and pharmacological interventions for insomnia among individuals with alcohol use disorder (AUD).

PROCEDURES

Comprehensive literature searches of psychological, medical, and educational databases were conducted through October 2016. Eligible studies evaluated the efficacy of an insomnia intervention, included a comparison condition, sampled individuals with AUD and either insomnia disorder or complaints of insomnia, assessed sleep-related outcomes, and provided relevant statistics to calculate between-group effect sizes. Effect sizes were estimated for sleep quality, days of alcohol abstinence, and symptoms of depression. Type of intervention (behavioral versus pharmacological) was tested as a moderator of intervention efficacy.

MAIN FINDINGS

Nine studies met eligibility criteria and were included in the final review and meta-analysis. Random-effects models indicated that intervention participants reported greater improvements in sleep quality (d+=0.62, 95% CI=0.28, 0.97) and symptoms of depression (d+=0.52, 95% CI=0.06, 0.98) than control participants. Participants reported significantly greater improvements in sleep quality in response to behavioral (d+=1.20, 95% CI=0.70, 1.70) as opposed to pharmacological (d+=0.43, 95% CI=0.19, 0.67) interventions. Behavioral (d+=0.74, 95% CI=0.31, 1.18) and pharmacological (d+=0.08, 95% CI=-0.64, 0.78) interventions did not have significantly different effects on depressive symptoms. Neither behavioral nor pharmacological interventions improved rates of alcohol abstinence.

CONCLUSIONS

Insomnia interventions improve sleep quality and reduce symptoms of depression among individuals with comorbid AUD. Given the methodological weaknesses of studies reviewed, additional research is needed to determine the efficacy of insomnia treatment in improving rates of alcohol relapse within this population.

Suicide and suicide attempts among women in the Manitoba Mothers and Fetal Alcohol Spectrum Disorder cohort: a retrospective matched analysis using linked administrative data

BACKGROUND

Women who give birth to children with fetal alcohol spectrum disorder (FASD) may be at increased risk for suicide; however, there are few data in this area. The objective of this study was to compare rates of suicide between women who had given birth to children with FASD and women who had not given birth to children with FASD during critical periods in their lives, including before pregnancy, during pregnancy, during the postpartum period (maternal death) and until the end of the study period.

METHODS

We conducted a retrospective cohort analysis of women with children born in Manitoba between Apr. 1, 1984, and Mar. 31, 2012 in whom FASD was diagnosed between Apr. 1, 1999, and Mar. 31, 2012, with follow-up until Dec. 1, 2013 (FASD group; n = 702). We generated a comparison group of women who had not given birth to children with FASD (n = 2097), matched up to 1:3 on date of birth of the index child, socioeconomic status and region of residence. We used linked administrative data to investigate suicide attempt and completion rates in the 2 groups. Regression modelling produced relative rates (RRs) adjusted for socioeconomic status and age at birth of the index child and was used to assess suicide risk.

RESULTS

The 2799 participants produced 40 390.21 person-years until the end of the study period. Compared to the comparison group, the FASD group had higher rates of suicide completion (adjusted RR 6.20 [95% confidence interval (CI) 2.36-16.31]), a higher number of women who attempted suicide after the postpartum period until the end of the study period (adjusted RR 4.62 [95% CI 2.53-8.43]) and a higher number of attempts after the postpartum period until the end of the study period (adjusted RR 3.92 [95% CI 2.30-6.09]).

INTERPRETATION

This study identified a group of women with increased rates of social complexities, mental disorders and alcohol use, which places them at risk for suicide. Interventions are needed that screen for suicidal behaviour in women who are at high risk to consume alcohol during pregnancy and have mental disorders.

Predictors for self-directed aggression in Italian prisoners include externalizing behaviors, childhood trauma and the serotonin transporter gene polymorphism 5-HTTLPR

Suicidal behavior and self-mutilation can be regarded as the expression of self-directed aggression and both are common in prison populations. We investigated the influence of externalizing behaviors, depressive symptoms, childhood trauma, 5-HTTLPR variants on self-directed aggression (N = 145) in a group of 702 male Italian prisoners. Participants were comprehensively evaluated, including for psychiatric disorders, impulsive traits, lifetime aggressive behavior [Brown-Goodwin Lifetime History of Aggression (BGHA)], hostility, violent behavior during incarceration, depressive symptomatology [Hamilton Depression Rating Scale (HDRS)], childhood trauma [Childhood Trauma Questionnaire (CTQ)]. Logistic regression analysis showed false discovery rate corrected independent main effects of externalizing behaviors: BGHA (P = 0.001), violent behavior in jail (P = 0.007), extraversion (P = 0.015); HDRS (P = 0.0004), Axis I disorders (P = 0.015), CTQ (P = 0.004) and 5-HTTLPR genotype (P = 0.02). Carriers of 5-HTTLPR high (LA LA ), intermediate (LA LG , SLA ) activity variants were more likely to have exhibited self-directed aggression relative to the low activity (LG LG , SLG , SS) variant: high/low: odds ratio (OR) = 2.3, 95% confidence interval (CI) 1.27-4.68, P = 0.007; intermediate/low: OR = 1.96, 95% CI 1.09-3.68, P = 0.025. The CTQ main effect was driven by physical abuse. There was no interactive effect of 5-HTTLPR and CTQ. Secondary logistic regression analyses in (1) all suicide attempters (N = 88) and (2) all self-mutilators (N = 104), compared with controls showed that in both groups, childhood trauma (P = 0.008-0.01), depression (P = 0.0004-0.001) were strong predictors. BGHA, violent behavior in jail predicted self-mutilation (P = 0.002) but not suicide attempts (P = 0.1). This study was able to distinguish differing influences on self-directed aggression between groups of closely related predictor variables within the externalizing behavioral domain. 5-HTTLPR had an independent, variant dosage effect.