Predisposing and Precipitating Factors for Suicide Among Alcoholics: Empirical Review and Conceptual Integration

Psychological dimensions in alcohol use disorder: comparing active drinkers and abstinent patients

Background

Alcohol use disorder (AUD) is a major public health concern due to its various physical, psychological, and social consequences. Despite regulatory differences, abstinence remains the primary treatment objective. Addressing the multifaceted nature of alcohol use disorder requires a comprehensive approach.

Methods

150 AUD patients (66%male) with a mean age of 54.10 ± 11.3 years were recruited for the study. Depression, impulsivity, alexithymia, and hopelessness were assessed to determine if there were significant differences in these dimensions between abstinent (N=72) and active drinkers (N=78).

Results

The study found significant differences in the psychological dimensions scores, active drinkers exhibited higher levels of depression, impulsivity, alexithymia, and hopelessness compared to abstinent patients.

Conclusion

Treatment outcomes for patients with AUD vary between regulatory agencies, but abstinence remains the safest and most preferred objective in managing AUD. Prioritizing abstinence-oriented interventions is crucial for achieving long term recovery and minimizing relapse risk. These results emphasize the intricate relationship between AUD and mental health issues, highlighting the need for comprehensive interventions addressing both alcohol consumption and associated psychological distress. Promoting abstinence (or at least reducing alcohol consumption) not only preserves mental health but also prevents life-threatening consequences such as suicide.

Exposure to alcohol outlets and risk of suicidal behavior in a Swedish cohort of young adults

BACKGROUND

Greater alcohol accessibility, for example in the form of a high density of alcohol outlets or low alcohol taxation rates, may be associated with increased risk of suicidal behavior. However, most studies have been conducted at the aggregate level, and some have not accounted for potential confounders such as socioeconomic position or neighborhood quality.

METHODS

In a Swedish cohort of young adults aged 18 to 25, we used logistic regressions to evaluate whether living in a neighborhood that included bars, nightclubs, and/or government alcohol outlets was associated with risk of suicide attempt (SA) or suicide death (SD) during four separate 2-year observation periods. Neighborhoods were defined using pre-established nationwide designations. We conducted combined-sex and sex-stratified analyses, and included as covariates indicators of socioeconomic position, neighborhood deprivation, and aggregate genetic liability to suicidal behavior.

RESULTS

Risk of SA was increased in some subsamples of individuals living in a neighborhood with a bar or government alcohol outlet (odds ratios [ORs] = 1.05 to 1.15). Risk of SD was also higher among certain subsamples living in a neighborhood with a government outlet (ORs = 1.47 to 1.56), but lower for those living near a bar (ORs = 0.89 to 0.91). Significant results were driven by, but not exclusive to, the male subsample. Individuals with higher aggregate genetic risk for SA were more sensitive to the effects of a neighborhood government alcohol outlet, pooled across observation periods, in analyses of the sexes combined (relative excess risk due to interaction [RERI] = 0.05; 95% confidence intervals [CI] 0.01; 0.09) and in the male subsample (RERI = 0.06; 95% CI 0.001; 0.12).

CONCLUSIONS

Although effect sizes are small, living in a neighborhood with bars and/or government alcohol outlets may increase suicidal behavior among young adults. Individuals with higher genetic liability for SA are slightly more susceptible to these exposures.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Alcohol use and its association with suicide attempt, suicidal thoughts and non-suicidal self-harm in two successive, nationally representative English household samples

BACKGROUND

Alcohol use is a risk factor for suicidal behaviour, yet the nature of the relationship is unclear. Most research on the topic is conducted in clinical populations, with few studies exploring this association across the general population.

AIMS

We investigated the association between specific domains of alcohol use and suicide attempt, suicidal thoughts and non-suicidal self-harm in a general population sample.

METHOD

A total of 14 949 adults who completed the 2007 or 2014 Adult Psychiatric Morbidity Survey were included. We measured alcohol use with the Alcohol Use Disorders Identification Test (AUDIT). Domains of alcohol use relating to risk categories, weekly consumption, binge drinking, dependence symptoms, harmful effects and concern from others were derived from relevant AUDIT items. Self-reported past year suicide attempt, suicidal thoughts and non-suicidal self-harm were measured with the Clinical Interview Schedule, Revised.

RESULTS

We found a linear association between total AUDIT score and outcomes. Three of six specific domains of alcohol use (dependence symptoms, harmful effects of drinking and binge drinking) were associated with increased odds of all three outcomes. There was no association of outcomes with the other domains of alcohol use.

CONCLUSIONS

We found evidence of a linear association between total AUDIT score and suicide attempt, suicidal thoughts and non-suicidal self-harm in a representative English general population sample. Our analyses suggest that where alcohol use significantly disrupts day-to-day functioning, this may underpin the relationship between alcohol use and suicide-related outcomes to a greater extent than higher alcohol consumption. Longitudinal research is needed to further understand these relationships.

Suicidal ideations among students attending vocational school in Germany: a cross-sectional study to identify prevalence and associated risk factors

Aim

Even though students attending vocational school are very vulnerable to the development of mental health problems, few studies identify the correlation between suicidal ideations and vocational education. Therefore, this study aimed to identify the prevalence and associated risk factors for suicidal ideations among vocational students in Germany.

Methods

We conducted a cross sectional survey with a total of 555 pupils. The pupils received a standardized questionnaire, assessing sociodemographic data, the use of protective factors, possible risk factors, traits for neuroticism and depressive symptoms. For our study, we excluded item 9 from the Beck depression index (BDI-II) to identify the prevalence of suicidal ideation.

Results

Our results show that the prevalence of suicidal ideation among students attending vocational school is 23.2%. A combination of feeling lonely, male sex, low importance of religion, little time for hobbies and BMI scores outside the norm show the highest risk for suicidal ideation and can be identified as significant predictors.

Conclusion

This cross-sectional study highlights the mental burden vocational students in Germany are confronted with and underlines the necessity of paying special attention to this group of young adults. Furthermore, it emphasizes the necessity of further studies on this topic, especially including larger student populations. The results should be used to decrease the significant loss of life caused by suicidal behavior in young adults.

Alcohol use in adolescence as a risk factor for overdose in the 1986 Northern Finland Birth Cohort Study

Background

Overdoses and poisonings are among the most common causes of death in young adults. Adolescent problem drinking has been associated with psychiatric morbidity in young adulthood as well as with elevated risk for suicide attempts. There is limited knowledge on adolescent alcohol use as a risk factor for alcohol and/or drug overdoses in later life.

Methods

Here, data from The Northern Finland Birth Cohort 1986 study with a follow-up from adolescence to early adulthood were used to assess the associations between adolescent alcohol use and subsequent alcohol or drug overdose. Three predictors were used: age of first intoxication, self-reported alcohol tolerance and frequency of alcohol intoxication in adolescence. ICD-10-coded overdose diagnoses were obtained from nationwide registers. Use of illicit drugs or misuse of medication, Youth Self Report total score, family structure and mother’s education in adolescence were used as covariates.

Results

In multivariate analyses, early age of first alcohol intoxication [hazard ratios (HR) 4.5, 95% confidence intervals (CI) 2.2–9.2, P < 0.001], high alcohol tolerance (HR 3.1, 95% CI 1.6–6.0, P = 0.001) and frequent alcohol intoxication (HR 1.9, 95% CI 1.0–3.4, P = 0.035) all associated with the risk of overdoses. Early age of first intoxication (HR 5.2, 95% CI 1.9–14.7, P = 0.002) and high alcohol tolerance (HR 4.4, 95% CI 1.7–11.5, P = 0.002) also associated with intentional overdoses.

Conclusions

Alcohol use in adolescence associated prospectively with increased risk of overdose in later life. Early age of first intoxication, high alcohol tolerance and frequent alcohol intoxication are all predictors of overdoses.

Investigating the nature of depressive experiences in adults who self-medicate low mood with alcohol

OBJECTIVE

This study sought to explore if individuals who self-medicate with alcohol experience higher levels of depression, and if symptom level experiences are affected by the behaviour of self-medication.

DESIGN

Data was from the Wave I (2001-2002) National Epidemiologic Survey on Alcohol and Related Conditions - NESARC. Only participants who experienced either one or both of the two stem questions which highlight the key symptoms of depression were included (n=13,753).

RESULTS

A one factor model of depression was supported. Experiences of suicidality were more likely to be endorsed by people who self-medicated, compared to those with low mood who do not use alcohol in this way. Typically, more common experiences of depression in the form of appetite difficulties, were less likely to be reported by those who self-medicated, compared to those who do not.

CONCLUSIONS

The findings aid understanding of the drinking patterns and other mental health correlates of those who engage in the behaviour of self-medication. Findings indicate that those who self-medicate are at a higher risk for suicidality, given the same level of depression. These findings highlight the importance of identifying these potentially problematic health behaviours as early as possible, due to these risks.

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.

Alcohol use disorder and non-fatal suicide attempt: findings from a Swedish National Cohort Study

BACKGROUND AND AIMS

Alcohol use disorder (AUD) is associated with increased risk of non-fatal suicide attempt. We aimed to measure the strength and mechanistic nature of the association between AUD and increased suicide attempt and determine any causal pathways and/or shared risk factors.

DESIGN

We used Cox proportional hazards models in population-level and co-relative analyses to evaluate the risk of first non-fatal suicide attempt as a function of previous AUD.

SETTING AND PARTICIPANTS

We used continuously updated longitudinal nationwide Swedish registry data on native Swedes born from 1950 to 1970 (n = 2 229 619) and followed from age 15 until 2012.

MEASUREMENTS

AUD and suicide attempt were identified using International Classification of Diseases (ICD)-8, ICD-9, and ICD-10 codes. AUD was also identified using pharmacy and criminal records. Genetic and family environmental risks were derived based on relatedness via the Multi-Generation Register and shared residency via the Population and Housing Census and the Total Population Register.

FINDINGS

AUD was robustly associated with suicide attempt in crude models (hazard ratio [HR] = 15.24 [95% CI: 14.92, 15.56]). In models adjusted for sociodemographic factors and psychiatric comorbidity, the association was attenuated: for women, HRs declined gradually across time, ranging from 5.55 (3.72, 8.29) during the observation period that ranged from age 15 to 19 years to 1.77 (1.65, 1.90) at age 40 or older. For men, the corresponding figures were 6.12 (4.07, 9.19) and 1.83 (1.72, 1.94); in contrast to women, risk of suicide attempt among men increased from age 15 to 29 before declining. In co-relative models, a residual association remained, consistent with a causal path from AUD to suicide attempt.

CONCLUSIONS

In Sweden, alcohol use disorder appears to be an important predictor of suicide attempt even in the context of other psychiatric disorders. The observed association is likely the result of features that jointly impact risk of alcohol use disorder and suicide attempts (genetic liability, psychiatric illness, and childhood stressors) and a potentially causal pathway, acting independently or in conjunction with one another.

Feasibility and acceptability of the mobile application for the prevention of suicide (MAPS)

Rates of Veteran suicide continue to be unacceptably high. Suicidal ideation and behavior are contextually and situationally based, limiting the ability of traditional prevention and assessment strategies to prevent acute crises. The Mobile Application for the Prevention of Suicide (MAPS) is a novel, smartphone-based intervention strategy that utilizes ecological momentary assessment to identify suicide risk in the moment and delivers treatment strategies in real-time. The app is personalized to each patient, utilizes empirically intervention strategies, and is delivered adjunctively to Veterans Affairs (VA) treatment as usual. This article outlines the MAPS intervention and presents results of an open trial to assess its feasibility and acceptability. Eight Veterans were recruited from aVeterans Affairs Medical Center (VAMC) psychiatric inpatient unit following hospitalization for either a suicide ideation or attempt. Veterans received MAPS for 2 weeks post-hospitalization. Veterans reported high levels of satisfaction with MAPS and all opted to extend their use of MAPS beyond the 2-week trial period. MAPS may be a useful adjunctive to treatment as usual for high-risk Veterans by allowing patients and their providers to better track suicide risk and deploy intervention strategies when risk is detected.

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

BACKGROUND

Alcohol consumption is related to both suicidal ideation and behaviour, but evidence regarding the effect of psychological interventions to reduce alcohol use on self-harm, suicidal behaviour and ideation is limited. Therefore, the aim of the current study was to conduct a systematic literature review and meta-analysis of the effect of alcohol-related psychological interventions on these outcomes at the individual level.

METHODS

We searched the Cochrane CENTRAL, Cochrane DARE, EMBASE, Medline, ProQuest, PsycINFO, PubMed, SCOPUS, and Web of Science electronic databases to 5 January 2021. We included all English-language papers worldwide utilising psychological interventions with a focus on harmful alcohol use and suicidal ideation, self-harm, and/or suicidal behaviour.

RESULTS

We identified 11 studies, nine provided sufficient numerical data for meta-analysis. Although the methods and effect sizes varied substantially in the studies, reducing alcohol may led to a reduction in self-harm and suicide attempt by the final follow-up assessment (Odds ratio [OR] 0.57, 95% confidence interval [CI] 0.33 to 0.97, 6 studies, 491 participants, I² = 0%). However, there was no apparent effect for these interventions on suicidal ideation or suicide deaths. There was no significant difference in effect by therapeutic approach. Neither intervention dose (in hours) nor duration (in months) significantly explained differences in treatment effectiveness.

CONCLUSIONS

Interventions targeting harmful alcohol consumption may contribute towards a reduction in self-harm at the individual level. However, there was no apparent effect of these interventions on suicidal ideation (measured either continuously or dichotomously) or suicide deaths.

Alcohol Intoxication and Suicide by Hanging in Poland

AIMS

An integral part of the World Health Organization (WHO) plan to reduce suicide by 10% by 2020 is to identify areas and demographic groups, which should be priority target groups for preventive activities. This study aimed to present the demographic differences between victims of suicide by hanging in the Warsaw metropolitan area, in Poland, by examining the sobriety of victims.

METHODS

Data for analysis were obtained from the documentation of the Department of Forensic Medicine (DFM) at the Medical University of Warsaw (MUW). The retrospective analysis included 358 out of 466 victims of suicides by hanging in the Warsaw metropolitan area, in Poland, recorded in the DFM documentation covering 2011-2013. The data gathered included age, gender, the cause of death, a post-mortem examination as well as the level of ethanol in the blood and muscles of victims.

RESULTS

In both groups, men accounted for a larger percentage of victims than women, P = 0.068. In the no-alcohol group, the victims were older than in the alcohol group (47.52 ± 19.21 vs. 40.88 ± 12.77) (P < 0.001). The majority of the studied population were victims aged 25-34 (22.90%), mainly men (20.95%). Young men were also the largest group among victims in the alcohol group (28.33%). The most numerous age group among no-alcohol group were older victims aged 55-64 (19.10%), especially men (16.29%).

CONCLUSION

Regardless of sobriety, men were the largest group of suicide victims in the study population, which means that men die suicide more often than women. Differences in gender proportions are related to age. In the studied population, it was primarily young victims, mainly men. These are the groups that should be priority target groups for preventive activities aimed at reducing the number of suicides. The presence of ethanol in more than half of the victims of suicide in the study population indicates that alcohol is an important suicidal risk factor.

Alcohol and the Risk of Railway Suicide

Suicide is one of the ten most common causes of death in the world. Of all deaths from suicide, 22% can be attributed to the use of alcohol, which means that every fifth suicide would not occur if alcohol were not consumed by the population. People under the influence of alcohol choose more radical and effective methods of dying by suicide, e.g., throwing themselves under a moving vehicle, such as a train. The presented analysis aimed to determine important risk factors affecting railway suicide in Poland and their relation to the state of alcohol intoxication of the victims, and the relationship between ethyl alcohol consumption and the phenomenon of suicide. Documentation obtained from the Department of Forensic Medicine at the Medical University of Warsaw, in the form of death registers and forensic medical records concerning examination and autopsy, was analyzed. This made it possible to identify suicide victims from among pedestrian victims of railway accidents recorded during the period under study. The research was carried out using unidimensional and multidimensional statistical analyses with IBM SPSS Statistics, version 25. Sober suicide victims were statistically significantly older than victims under the influence of alcohol; alcohol concentration was correlated with the age of the victims-the older the victims were, the higher the alcohol concentration. A significantly higher number of deaths attributed to suicide by sober victims was observed in autumn compared to other seasons. Multidimensional analysis showed a statistically significant effect of age and season on the probability of dying by suicide under the influence of alcohol-this probability decreases with the age of the victims and is also significantly lower in autumn. The observed relationship between age and the presence of alcohol in suicide victims can be the cause of railway suicides. Knowledge of the mechanisms of seasonal variability of suicidal behavior can help to develop effective strategies to prevent railway suicides. It is necessary to improve the system of reporting railway suicides, as only reliable statistics provide the possibility of assessing both the scale of the problem and the effectiveness of actions taken.

Alcohol Use Disorder and Risk of Suicide in a Swedish Population-Based Cohort

OBJECTIVE

The authors examined the association between alcohol use disorder (AUD) and risk of suicide, before and after accounting for psychiatric comorbidity, and assessed the extent to which the observed association is due to a potentially causal mechanism or genetic and familial environmental confounding factors that increase risk for both.

METHODS

Longitudinal population-wide Swedish medical, criminal, and pharmacy registries were used to evaluate the risk of death by suicide as a function of AUD history. Analyses employed prospective cohort and co-relative designs, including data on 2,229,880 native Swedes born between 1950 and 1970 and observed from age 15 until 2012.

RESULTS

The lifetime rate of suicide during the observation period was 3.54% for women and 3.94% for men with AUD, compared with 0.29% and 0.76% of women and men, respectively, without AUD. In adjusted analyses, AUD remained robustly associated with suicide: hazard ratios across observation periods ranged from 2.61 to 128.0 among women and from 2.44 to 28.0 among men. Co-relative analyses indicated that familial confounding accounted for some, but not all, of the observed association. A substantial and potentially causal relationship remained after accounting for a history of other psychiatric diagnoses.

CONCLUSIONS

AUD is a potent risk factor for suicide, with a substantial association persisting after accounting for confounding factors. These findings underscore the impact of AUD on suicide risk, even in the context of other mental illness, and implicate the time frame shortly after a medical or criminal AUD registration as critical for efforts to reduce alcohol-related suicide.

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.

The role of childhood adversities, FKBP5, BDNF, NRN1, and generalized self-efficacy in suicide attempts in alcohol-dependent patients

Background

Alcohol-dependent (AD) patients report higher number of adverse childhood experiences (ACEs), develop poor social skills, and have a higher rate of suicide attempts than the general population. We hypothesize that the association between ACEs and lifetime suicide attempts in AD patients is mediated by generalized self-efficacy and selected functional single nucleotide polymorphisms (SNPs) in genes involved in the stress response and neuroplasticity, including: FKBP5 rs1360780, BDNF rs6265, and NRN1 rs1475157.

Methods

176 AD patients and 127 healthy controls self-reported ACEs with the ACE Study questionnaire and three additional questions that inquired about ACE categories of acute stress; generalized self-efficacy—with the Generalized Self-Efficacy Scale. Genotyping for the three analysed SNPs was performed according to the manufacturer’s standard PCR protocol. Hypotheses were tested with bivariate analyses, multiple regression model, and mediation models.

Results

Higher levels of generalized self-efficacy were associated with a blunted effect of ACEs on the risk of suicide attempts. The prevalence of the three analyzed SNPs genotypes and alleles did not differ between AD patients with a positive vs. negative lifetime history of suicide attempt and was not associated with GSES scoring.

Conclusions

Generalized self-efficacy should be considered as a target for psychotherapeutic interventions aimed at reducing the risk of suicide attempts in AD patients who were exposed to childhood victimization. The negative results concerning the hypothesized role of the three analysed SNPs should be carefully interpreted due to the relatively small study sample, but represent a theoretical foundation for further research studies with larger study samples.

Electronic supplementary material

The online version of this article (10.1007/s43440-020-00080-8) contains supplementary material, which is available to authorized users.

Identifying alcohol problems among suicide attempters visiting the emergency department

BACKGROUND

Many suicide attempters brought to our emergency department (ED) have been found to have alcohol problems, and this should be taken serious consideration because alcohol use disorder is a risk factor for suicide reattempt. In this study, we aimed to estimate the effectiveness of alcohol-related biochemical markers and Alcohol Use Disorder Identification Test Consumption (AUDIT-C) in suicide attempters who visited our ED based on the gold standard for clinical diagnosis used by psychiatrists for alcohol use disorder. Moreover, we aimed to search for a significant standard when clinicians make correct predictions about alcohol use disorder using these markers.

METHODS

Among the subjects who visited ED following a suicide attempt, a total of 203 subjects were selected. Following a psychiatric interview, the subjects who met the criteria for alcohol abuse or alcohol dependence according to DSM-IV-TR in the past year were defined as the "alcohol use disorder" group. Although some subjects did not meet these criteria, men with a weekly alcohol intake of ≥14 drinks and women with a weekly alcohol intake of ≥7 drinks were classified as the "risky drinking" group. AUDIT-C was used as a self-report; further, aspartate aminotransferase, gamma-glutamyltransferase (GGT), and carbohydrate-deficient transferrin (CDT) were assayed using standard methods, and GGT-CDT was calculated using this formula: 0.8 × ln(GGT) + 1.3 × ln(%CDT).

RESULTS

In total, 88 subjects met the criteria for alcohol use disorder and 115 were included in the reference group. In the screening for alcohol use disorder, the AUC of AUDIT-C was 0.89 for men and 0.87 for women. In the screening for risky drinking, the AUC of AUDIT-C was 0.99 for men and 0.93 for women. Compared with other biochemical markers, AUDIT-C showed the highest AUC value for screening for both alcohol use disorder and risky drinking, with the trend being more prominent in men.

CONCLUSIONS

Among the biochemical markers, AUDIT-C yielded the highest sensitivity, specificity, and accuracy in diagnosing alcohol use disorder among suicide attempters in ED. Comparison of results revealed that the use of AUDIT-C with biochemical markers or its use alone can help screen for alcohol use disorder or risky drinking in clinical settings.

Refining Psychological, Substance Use, and Sociodemographic Predictors of Suicide Ideation and Attempts in a National Multiethnic Sample of Adults, 2008-2013

The purpose of this study was to examine psychological, substance use, and sociodemographic predictors of 12-month suicide ideation and attempts across six US racial/ethnic groups-white, Latino/a, Black, Asian or Pacific Islander (A/PI), American Indian or Alaska Native (AI/AN), and multiracial adults. Multiple logistic regression analyses were conducted for 218,765 adults who participated in the 2008-2013 National Survey on Drug Use and Health. Overall, commonly cited factors were associated with increased risk for suicide ideation and attempt for some racial/ethnic groups, but not for others. As one example, 12-month depression was associated with 12-month suicide attempt for A/PI, AI/AN, Latino/a, and white, but not for Black or multiracial adults. Alcohol abuse and dependence were also associated with suicide attempt for AI/AN, Black, and white respondents but not for other racial/ethnic groups. Risk factors for suicide ideation and attempt may not increase risk universally. More theoretically supported research is needed.

Predisposing and protective factors influencing suicide ideation, attempt, and death in patients accessing substance use treatment: a systematic review and meta-analysis protocol

BACKGROUND

The lifetime risk of suicide in patients with substance use disorder is five to ten times the risk in the general population. Critically, up to 19% of patients continue to think about and attempt suicide even after accessing treatment. Therefore, suicidality represents a significant clinical concern in patients struggling with substance use that warrants careful investigation of the factors involved. While most previous research has relied on limited cross-sectional designs, a growing number of prospective studies are improving our understanding of the factors involved. However, a systematic study of these factors has not yet been conducted.

METHODS

The primary objective of this review and possible meta-analysis will be to identify key risk and protective factors for suicide ideation, attempt, and death in patients accessing substance use treatment, guided by current models of suicide. Secondary and tertiary objectives will be to obtain pooled effect sizes for the factors identified and to disaggregate factors for suicidality before and after treatment, and for suicidal thought versus action. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we will conduct an electronic search of the literature using the databases Embase, Medline, PsycINFO, and Web of Science. Two authors will independently screen studies based on pre-specified inclusion and exclusion criteria, extract relevant data, and assess study quality. Observational and randomized-controlled studies will be included, whereas case-studies and reviews will be excluded. We will extract data on risk and protective factors associated with suicide ideation, attempt (odds or risk ratios), and death (hazard ratio). Given sufficient data (> 5 studies), we will calculate pooled effects using comprehensive meta-analysis.

DISCUSSION

This systematic review will contribute to our knowledge of risk and protective factors for suicidality in patients before and after treatment. Understanding these factors will help define areas of research for further investigation to ultimately inform risk assessment and prevention strategies.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO (reference number: CRD42018076260).

Relationships Between Components of Emotional Intelligence and Suicidal Behavior in Alcohol-dependent Patients

OBJECTIVES

The importance of investigating various emotional skills in assessment of suicide risk in alcohol-dependent (AD) individuals has recently become the focus of increasing interest. The objective of this study was to explore the relationships between self-reported components of emotional intelligence and lifetime prevalence of suicide attempts in a clinical sample of AD subjects.

METHODS

A group of 80 inpatients entering an alcohol treatment program in Warsaw, Poland, was recruited. Baseline information about demographics, psychopathological symptoms, personality, and severity of alcohol problems was obtained. The Schutte Self-Report Emotional Intelligence Test was utilized for assessment of emotional processing. Lifetime history of suicide attempts was obtained from the MINI International Neuropsychiatric Interview.

RESULTS

After accounting for affect-related suicide risk factors (severity of depression, anxiety, neuroticism), and also other significant predictors (eg, age, sex, history of childhood abuse), mood regulation/optimism deficits remained a significant correlate of lifetime suicide attempts in AD patients. In the mediation models, mood regulation appeared to fully mediate the relationship between history of suicide attempts and depression, and also neuroticism.

CONCLUSIONS

The results of this study support the evidence that poor mood regulation might be related to the risk for suicidal behavior in AD individuals. These findings point towards the significance of addressing the issue of emotion-related skills in the therapy of those AD subjects who are at risk for suicide.

Addiction and Suicide: A Review

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

The relationship between alcohol abuse and suicide risk according to smoking status: A cross-sectional study

BACKGROUND

Considering the rising suicide risk rate, we investigated the associations between alcohol abuse, smoking, and suicide risk.

METHODS

Participants were 21,654 (male: 9,729, female: 11,925) responders of the National Nutrition Survey from 2013 to 2015 in Korea. Associations between alcohol, smoking, and suicide risk were analyzed using logistic regression and path analysis. The Alcohol Use Disorder Identification Test (AUDIT) measured alcohol consumption levels.

RESULTS

Among participants, 1,718 (male: 602, female: 1,116) presented a suicide risk related to alcohol and smoking. Men's odds ratio of suicide ideation was the highest among those reporting current smoking and AUDIT scores ≥ 20, at 83.75 (95% confidence interval [CI] = 48.07-145.94); that of suicide ideation was the highest for men reporting current smoking and AUDIT scores ≥ 20, at 121.49 (CI = 48.92-301.67); and that of suicide attempts was the highest for men reporting current smoking and AUDIT scores of 16-19, at 256.341 (CI = 77.12-852.05). Women's odds ratio of suicide ideation was the highest for those reporting current smoking and AUDIT scores ≥ 20, at 21.92 (CI = 7.19-66.80); that of suicide ideation was the highest for women reporting current smoking and AUDIT scores ≥ 20, at 19.26 (CI = 4.52-82.17); and that for suicide attempts was the highest for those reporting past smoking and AUDIT scores 8-15, at 104.64 (CI = 10.32- < 999.99). As a result of the path analysis, six paths were fully adopted. Smoking status had a statistically significant positive effect on attempted suicide (t = 146.50, p < .001). AUDIT scores were found to have a significant positive effect on attempted suicide (t = 2503.74, p < .001).

LIMITATIONS

Results must be interpreted within the study design context. Suicidality does not assess any depressive episode. the sample did not include persons who had committed suicide. As suicidal ideation, plans, and attempts are on a spectrum it is difficult to find valid and appropriate, as well as culturally-sensitive, screening questions for suicidal risk that are comparable across international studies. The data used in this study were based on self-reports of smoking, drinking, and suicide risk.

CONCLUSIONS

The combination of alcohol use and smoking was associated with greater suicide risk than were alcohol and smoking separately.

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.

Influence of comorbid alcohol use disorders on the clinical patterns of major depressive disorder: A general population-based study

BACKGROUND

To compare the symptom patterns of major depressive disorder (MDD) among subjects with MDD and 1) no alcohol use disorder (AUD), 2) alcohol abuse and 3) alcohol dependence, respectively.

METHODS

In a general population survey of 38,694 French individuals, MDD and AUDs were assessed using the Mini International Neuropsychiatric Interview 5.0.0 (MINI). A total of 4339 subjects (11.2%) in the sample met the criteria for MDD. Among them, 413 (9.5%) AUD subjects were identified: 138 (3.2%) for alcohol abuse and 275 (6.3%) for alcohol dependence. The associations of each of the ten MDD criteria of the MINI and psychiatric clinical features were compared among the three groups. The relative profiles of 'MDD + AUD' vs. 'MDD alone' were determined using a multivariable stepwise regression model.

RESULTS

With the noAUD group as the reference, sadness (OR = 0.46; 95%CI, 0.29-0.74) and anhedonia (OR = 1.66; 95%CI, 1.06-2.73) were only associated with alcohol abuse. Sleep disorders (OR = 2.07; 95%CI, 1.51-2.88), feelings of guilt (OR = 1.41; 95%CI, 1.05-1.90), diminished concentration/indecisiveness (OR = 1.52; 95%CI, 1.12-2.07) and thoughts of death (OR = 1.95; 95%CI 1.49-2.55) were only associated with alcohol dependence. Weight or appetite variations were both associated with alcohol abuse (OR = 1.7; 95%CI, 1.15-2.53) and dependence (OR = 1.41; 95%CI, 1.06-1.88). Bipolar disorder and PTSD were only associated with alcohol dependence. Psychotic features, previous suicide attempts, and panic disorder were more frequent in the MDD-AUD group.

CONCLUSION

MDD-AUD subjects displayed a more severe profile with specific symptomatology and comorbidity profiles compared to MDD-only subjects.

A comprehensive model of predictors of suicide attempt in heavy drinkers: Results from a national 3-year longitudinal study

BACKGROUND

Heavy drinkers are at high risk for suicide attempt and suicide. Multiple factors, when examined in isolation, have been implicated in the risk of suicide attempt in this population. In this report, we present a comprehensive model of the 3-year risk of suicide attempt in heavy drinkers using a longitudinal nationally representative study, the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC; wave 1, 2001-2002; wave 2, 2004-2005).

METHODS

We used structural equation modeling to simultaneously examine effects of four broad groups of clinical factors previously identified as potential predictors of attempted suicides: 1) alcohol use disorder severity, 2) severity of comorbidity, 3) sociodemographic characteristics and 4) help-seeking for alcohol problems. Heavy drinking was defined as drinking 5 or more drinks in a day more than once a week in the month prior to Wave 1.

RESULTS

About 1.5% of the 1573 heavy drinker participants (i.e., 5.1% of the NESARC sample) attempted suicide during the 3-year follow-up period. After adjusting for all other factors, several factors independently predicted attempted suicides: the alcohol use disorder liability factor measured by DSM-IV-TR criteria for alcohol abuse and dependence and two dimensions of psychopathology, the general psychopathology factor accounting for the shared effects of all comorbid psychiatric disorders and the externalizing dimension accounting for the shared effects of comorbid substance use disorders. No other factor predicted this risk in addition.

CONCLUSION

This model may help identify individuals with heavy drinking at high risk of suicide and develop more effective suicide prevention strategies.

Neuroticism and suicide in a general population cohort: results from the UK Biobank Project

BACKGROUND

Neuroticism has often been linked to suicidal thoughts and behaviour.

AIMS

To examine whether neuroticism is associated with suicide deaths after adjusting for known risks.

METHOD

UK Biobank participants (n = 389 365) were assessed for neuroticism as well as social, demographic and health-related variables at study entry and followed for up to 10 years. Suicide risk was modelled using Cox regression stratified by gender.

RESULTS

Neuroticism increased the risk of suicide in both men (hazard ratio (HR) = 1.15, 95% CI 1.09-1.22) and women (HR = 1.16, 95% CI 1.06-1.27). In a subsample who were assessed for mood disorders, neuroticism remained a significant predictor for women (HR 1.25, 95% CI 1.03-1.51) but not for men.

CONCLUSIONS

Screening and therapeutic interventions for neuroticism may be important for early suicide prevention.

DECLARATION OF INTEREST

None.

Deliberate self-harm behavior among young violent offenders

Deliberate self-harm behavior (DSH) can have profound effects on a person's quality of life, and challenges the health care system. Even though DSH has been associated with aggressive interpersonal behaviors, the knowledge on DSH in persons exhibiting such behaviors is scarce. This study aims to (1) specify the prevalence and character of DSH, (2) identify clinical, neurocognitive, psychosocial, and criminological characteristics associated with DSH, and (3) determine predictors of DSH among young violent offenders. Data were collected from a nationally representative cohort of 270 male violent offenders, 18-25 years old, imprisoned in Sweden. Participants were interviewed and investigated neuropsychologically, and their files were reviewed for psychosocial background, criminal history, mental disorders, lifetime aggressive antisocial behaviors, and DSH. A total of 62 offenders (23%) had engaged in DSH at some point during their lifetime, many on repeated occasions, yet without suicidal intent. DSH was significantly associated with attention deficit hyperactivity disorder, mood disorders, anxiety disorders, various substance use disorders, being bullied at school, and repeated exposure to violence at home during childhood. Mood disorders, anxiety disorders, and being bullied at school remained significant predictors of DSH in a total regression model. Violent offenders direct aggressive behaviors not only toward other people, but also toward themselves. Thus, DSH must be assessed and prevented in correctional institutions as early as possible, and more knowledge is needed of the function of DSH among offenders.

Supportive text messages for patients with alcohol use disorder and a comorbid depression: a protocol for a single-blind randomised controlled aftercare trial

INTRODUCTION

Alcohol use disorders (AUDs) and mood disorders commonly co-occur, and are associated with a range of negative outcomes for patients. Mobile phone technology has the potential to provide personalised support for such patients and potentially improve outcomes in this difficult-to-treat cohort. The aim of this study is to examine whether receiving supporting SMS text messages, following discharge from an inpatient dual diagnosis treatment programme, has a positive impact on mood and alcohol abstinence in patients with an AUD and a comorbid mood disorder.

METHODS AND ANALYSIS

The present study is a single-blind randomised controlled trial. Patients aged 18-70 years who meet the criteria for both alcohol dependency syndrome/alcohol abuse and either major depressive disorder or bipolar disorder according to the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders IV Axis I will be randomised to receive twice-daily supportive SMS text messages for 6 months plus treatment as usual, or treatment as usual alone, and will be followed-up at 3, 6, 9 and 12 months postdischarge. Primary outcome measures will include changes from baseline in cumulative abstinence duration, which will be expressed as the proportion of days abstinent from alcohol in the preceding 90 days, and changes from baseline in Beck Depression Inventory scores.

ETHICS AND DISSEMINATION

The trial has received full ethical approval from the St. Patrick's Hospital Research Ethics Committee (protocol 13/14). Results of the trial will be disseminated through peer-reviewed journal articles and at academic conferences.

TRIAL REGISTRATION NUMBER

NCT02404662; Pre-results.

Addiction Severity and Suicidal Behaviors Among Persons Entering Treatment

The aim of this study was three-fold: to compare the rates for suicidal behaviors based on the problem substance, to look at the association between addiction severity and suicidal behaviors, and to identify the components of addiction severity associated with suicidal behaviors. Addiction Severity Index databases from three public rehabilitation centers were merged for analyses, yielding 6,551 evaluations. The rates for suicidal behaviors among those who have a problem with both alcohol and a drug are higher than for those who have a problem with any single substance. The effect of addiction severity on suicidal behaviors persists even when other problem areas are taken into account. Thus, clinicians must pay closer attention to persons with both alcohol and drug problem.

A meta-analysis of acute use of alcohol and the risk of suicide attempt

BACKGROUND

No review has used a meta-analytic approach to estimate common odds ratios (ORs) for the effect of acute use of alcohol (AUA) on suicide attempts. We aim to report the results of the first meta-analysis of controlled epidemiological studies on AUA and suicide attempt.

METHOD

The English-language literature on Medline, PsycINFO and Google Scholar was searched for original articles and critical review on AUA and suicide attempt (period 1996-2015). Studies had to report an OR estimate for this association. Common ORs and 95% confidence intervals (CIs) from random effects in meta-analyses for any AUA and two levels of alcohol use on suicide attempt were calculated.

RESULTS

In all, seven studies provided OR estimates for the likelihood of suicide attempt by AUA, compared with those who did not drink alcohol. Studies used case-control (n 3) and case-crossover designs (n 4). Meta-analysis revealed a common OR of 6.97 (95% CI 4.77-10.17) for any AUA. Using four studies, 'low levels of acute drinking' resulted in an OR of 2.71 (95% CI 1.56-4.71) and 'high levels' had an OR of 37.18 (95% CI 17.38-79.53).

CONCLUSIONS

AUA is associated with increased likelihood of a suicide attempt, particularly at high doses. Such data should be incorporated into estimates of the burden of disease associated with alcohol use, which are currently limited by a consideration of only alcohol's chronic effects. Future research should focus on the mechanisms through which AUA confers risk for attempt.

Abdominal self-stabbing: A case report

While abdominal stabbings are frequently associated with homicides, abdominal self-stabbing is uncommon and poses a challenge for the investigators. In cases of sharp force trauma, the presence of hesitation cuts over the neck and extremities help to distinguish self-inflicted injuries from homicides. Hesitation cuts are not associated with self-inflicted sharp force injuries to the abdomen, and thus are of limited use in distinguishing suicidal from homicidal abdominal stab wounds. In this study, we present a case of self-inflicted abdominal stabbing along with a detailed review of literature to help elucidate such cases.

Role of Demographic and Personality Factors in Mediating Vulnerability to Suicide Attempts under Intoxication with Alcohol: A Record-based Exploratory Study

BACKGROUND

Identifying those who are likely to make suicide attempts under alcohol intoxication has important implications for management and prevention of further suicidal behavior.

AIMS

To identify the frequency of suicide attempts made under the influence of alcohol and the percentage of impulsive suicide attempts among them. We also aimed to identify predictors of attempted suicide under intoxication with alcohol.

SETTING AND DESIGN

Record-based study carried out at a tertiary care hospital.

MATERIALS AND METHODS

The clinical charts of consecutive suicide attempters (n = 147) who presented to the crisis intervention clinic from July 2013 to June 2014 were reviewed, and relevant data were extracted. The participants were divided into three groups - nonusers of alcohol (n = 85), alcohol users who did not attempt under intoxication (n = 31) and alcohol users who attempted under intoxication (n = 31). These groups were compared on various sociodemographic and clinical variables. Logistic regression was done to identify predictors of suicide attempt under intoxication.

STATISTICAL ANALYSIS USED

Chi-square (χ²) test, one-way ANOVA (F) test and backward stepwise logistic regression.

RESULTS

About 21.08% of all suicide attempts occurred under alcohol intoxication. Such subjects were more likely to be older (F = 12.428, P < 0.001), male (χ² = 87.367, P < 0.001), married (χ² = 6.787, P = 0.034), employed (χ² = 41.778, P < 0.001), and fewer years of formal schooling (F = 3.312, P = 0.039). Physical methods (hanging) were used more often in this group (χ² = 19.510, P = 0.012). In regression analysis, only marital status and living condition emerged as predictors of attempt under intoxication (odds ratios 4.52 [confidence interval (CI) 1.34-15.24, P = 0.015] and 5.67 [CI 1.17-27.39, P = 0.031] respectively).

CONCLUSION

Certain demographic features may help us in identifying those who are more likely to make attempts under intoxication. The role of personality factors as potential mediators of such behavior needs further exploration.

Differences between female suicidal patients with family history of suicide attempt and family history of completed suicide

BACKGROUND

Family history of suicidal behavior and suicide are both risk factors for suicide. However, the effects of family history of suicide versus suicide attempts on patient suicidal behavior remain unclear. The aim of the present study was to understand if family history of suicide as compared to family history of suicide attempts or no family history of suicidal behavior evidences different associations with suicidal behavior among psychiatric patients.

METHOD

Participants included 157 female patients between the ages of 18 and 65years admitted at the Dr. Braulio A. Moyano Neuropsychiatric Women's Hospital.

RESULTS

Seventy-nine patients (50.3%) reported no family history of suicidal behavior (NFHSB), while 78 patients (49.7%) reported a family history of suicidal behavior. Specifically, 41 patients (26.1%) reported a family history of suicide attempt (FHSA) and 37 patients (23.6%) reported a family history of suicide (FHS). These groups showed significant differences between family history of psychopathology and number of previous suicide attempts. Patients with an FHSA were more likely to present with a greater number of previous suicide attempts as compared to patients with NFHSB and FHS.

CONCLUSION

There is an association between the number of suicide attempts and family history of suicide attempts in female patients hospitalized for suicidal behavior.

The burden of alcohol use disorders in US military veterans: results from the National Health and Resilience in Veterans Study

AIMS

To analyze data from a large, contemporary, nationally representative sample of US veterans to evaluate: (1) the prevalence of life-time alcohol use disorder (AUD) and past-year AUD; (2) common psychiatric comorbidities associated with life-time AUD; and (3) correlates of life-time and past-year probable AUD.

DESIGN

Data were analyzed from the National Health and Resilience in Veterans Study (NHRVS), a web-based survey of a random probability sample of a contemporary, nationally representative sample of US military veterans.

SETTING

United States.

PARTICIPANTS

Nationally representative sample of 3157 US veterans aged 21 years and older.

MEASUREMENTS

Life-time alcohol abuse and dependence were assessed according to DSM-IV diagnostic criteria using the Mini International Neuropsychiatric Interview, and combined into a single variable: AUD. Past-year probable AUD was assessed using the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C). Correlates of AUD, including psychiatric comorbidities, suicidality and demographic characteristics, were also assessed.

FINDINGS

The prevalence of life-time AUD and past-year probable AUD was 42.2% [95% confidence interval (CI) = 40.5-43.9%)] and 14.8% (95% CI = 13.6-16.0%), respectively. Compared with veterans without AUD, those with life-time AUD had substantially elevated rates of life-time and current mood and anxiety disorders [odds ratios (ORs) = 2.6-4.1], drug use disorder (OR = 10.7), life-time suicide attempt (OR = 4.1) and current suicidal ideation (OR = 2.1). Younger age, male sex, lower education, lower annual household income and greater number of life-time traumatic events were associated independently with life-time AUD. Younger age, male sex, unpartnered marital status and a life-time diagnosis of major depressive disorder were associated independently with past-year probable AUD.

CONCLUSIONS

More than 40% of US military veterans have a life-time history of alcohol use disorder. Veterans with a life-time history of alcohol use disorder have substantial comorbid psychiatric burden, including elevated rates of suicidal ideation and attempts. Certain socio-demographic (e.g. younger age, male sex, lower education) and clinical (e.g. trauma burden, history of depression) characteristics are associated with increased risk of AUD.

What Can Influence Iranian Suicide Attempters to Go Through the Process of Non-Fatal Suicide Act Once Again? A Preliminary Report

The thrust of this study was to examine some of the psycho-social risk factors for the recurrence of non-fatal suicide attempt in a sample of 1121 inmates admitted between April 2012 to June 2013 at the toxicology emergency ward, Noor Medical Centre, Isfahan, Iran. Out of the total participants, 240 of them reported history of suicide attempt and assumed the status of case group. The remaining 881 patients were admitted first their attempt and constituted the control group. Cases were compared to the controls with respect to select demographic features (i.e. age, sex, education, occupation, marital status, type of residence, and locale), current suicide attempt method, family history of suicide and drug abuse, history of psychiatric disorder, physical ailment and physical disability, substance abuse and alcohol use, psychiatric diagnosis, and recent life hassles (i.e. interpersonal, occupational, financial, medical, and home affairs). We used a structured interview schedule to interview the participants. Psychiatric diagnosis was based on the DSM-IV criteria. Data were computer analyzed using SPSS.21 and administering statistical analysis including Chi Square, t-student, and logistic regression. Demographic risk factors for recurrence of suicide attempts at the univariate level included occupational status [Crud odds Ratio (COR) = 0.53] and type of residence (COR = 1.40). Medical and psychiatric risk factors at the univariate level included substance abuse (COR = 1.97), physical ailment (COR = 1.76), alcohol use (COR = 1.84), psychiatric disorder (COR = 3.69), and history of suicide in the family of origin (COR = 1.86). Recent life hassles risk factors at the univariate level included financial constraints (COR = 1.46) and medical emergencies (COR = 3.48). A multivariate logistic regression model identified five variables (i.e. substance abuse, alcohol use, psychiatric illness, suicide in family, and medical emergencies) that were statistically associated with an increased risk for recurrence of nonfatal suicide attempt. The model predicted chances of repeating suicide attempt correctly 79 % of the time. These observations indicate that people who report to the toxicology emergency ward for nonfatal suicide not only need immediate relief but also careful psychiatric and social assessments which subsequently may lead to psychiatric admission and comprehensive community interventions.

The timing of general population and patient suicide in England, 1997-2012

BACKGROUND

There have been conflicting findings on temporal variation in suicide risk and few have examined the phenomenon in clinical populations. The study investigated seasonal and other temporal patterns using national data.

METHODS

Data on 73,591 general population and 19,318 patient suicide deaths in England between 1997 and 2012 were collected through the National Confidential Inquiry into Suicide examining suicide rates in relation to month of the year, day of the week, and individual days of national or religious significance.

RESULTS

Suicide incidence fell over successive months of the year and there was evidence of an overall spring peak. Monday was associated with the highest suicide rates and in the patient population this effect appeared to be more pronounced in those aged over 50 or those who lived alone. Suicide risk was significantly lower during Christmas, particularly for women. There was a peak in suicide on New Year's Day in the general population. Other 'special days' were not associated with a change in suicide incidence.

LIMITATIONS

We were limited to identifying associations between the variables investigated and were unable to explore causal mechanisms. We did not carry out comprehensive multi-variable adjustment in our regression models.

CONCLUSIONS

There is substantial seasonal and temporal variation in suicide deaths, and there appears to be some evidence in the clinical as well as the general population in England. Clinical services should be aware of the risk of suicide just after the weekend, especially in people who live alone, and the potential need for closer supervision during this period.

Substance misuse in life and death in a 2-year cohort of suicides

BACKGROUND

Although substance misuse is a key risk factor in suicide, relatively little is known about the relationship between lifetime misuse and misuse at the time of suicide.

AIMS

To examine the relationship between substance misuse and subsequent suicide.

METHOD

Linkage of coroners' reports to primary care records for 403 suicides occurring over 2 years.

RESULTS

With alcohol misuse, 67% of the cohort had previously sought help for alcohol problems and 39% were intoxicated at the time of suicide. Regarding misuse of other substances, 54% of the cohort was tested. Almost one in four (38%) tested positive, defined as an excess of drugs over the prescribed therapeutic dosage and/or detection of illicit substances. Those tested were more likely to be young and have a history of drug misuse.

CONCLUSIONS

A deeper understanding of the relationship between substance misuse and suicide could contribute to prevention initiatives. Furthermore, standardised toxicology screening processes would avoid diminishing the importance of psychosocial factors involved in suicide as a 'cause of death'.

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.

Analysis of Deliberate Self-Wrist-Cutting Episodes Presenting to the Emergency Department

BACKGROUND

Previous suicide attempts increase the risk of a completed suicide. However, a large proportion of patients with deliberate self-wrist cutting (DSWC) are often discharged without undergoing a psychiatric interview.

AIMS

The aims of this study were to investigate the differences in the characteristics and outcomes of patients with DSWC and those with deliberate self-poisoning (DSP) episodes. The results of this study may be used to improve the efficacy of treatment for DSWC patients.

METHOD

We retrospectively reviewed the medical records of 598 patients with DSWC and DSP who were treated at the emergency department of Seoul Saint Mary's Hospital between 2008 and 2013. We assessed sociodemographic information, clinical variables, the reasons for the suicide attempts, and the severity of the suicide attempts.

RESULTS

A total of 141 (23.6%) patients were included in the DSWC group, and 457 (76.4%) were included in the DSP group. A significantly greater number of patients in the DSWC group had previously attempted suicide (p = .014). A total of 63 patients (44.7%) in the DSWC group and 409 patients (89.5%) in the DSP group underwent psychiatric interviews.

CONCLUSION

More DSWC patients had previously attempted suicide, but fewer of them underwent psychiatric interviews compared with the DSP patients.

[Sociodemographic Traits and Comorbidities in Pathological Gamblers With a Suicide Attempt in Spain]

OBJECTIVE

Suicide is the first cause of non-natural death in Spain. Among addictive disorders, pathological gambling is one the most significant independent risk factors for suicidal behavior. The objective of this study is to describe and compare the sociodemographic traits, comorbidity and attempt characteristics, between suicide attempters who fulfill diagnostic criteria for pathological gambling and those who do not.

METHODS

A total of 345 patients admitted to the emergency department of a University Hospital in Madrid between 1999 and 2004 were interviewed for this study. To describe and compare the demographic characteristics, comorbidity and those related to attempted suicide, using logistic regression models adjusted for sex and age were used.

RESULTS

Suicide attempters who fulfilled diagnostic criteria for pathological gambling were predominantly male, with a low education level, and had more offspring. Furthermore, these patients had more comorbidities, such as: global substance dependence, nicotine, cocaine and opioid dependence.

CONCLUSIONS

The present study suggests that pathological gamblers represent a distinct subgroup among suicide attempters, with particular characteristics, similar to those found in pathological gamblers in the general population.

Alcohol Abuse and Suicide Attempt in Iran: A Case-Crossover Study

Alcohol use and its disorders are associated with increased risk of suicidal behaviors Research has shown that 6-8% of those who use alcohol have a history of suicide attempt. Given the prohibition of alcohol use legally, the increased alcohol consumption, and the lack of strong evidence in favor of its use associated with suicide in Iran, this study was conducted to determine the link between suicide attempt and alcohol abuse. The case-crossover method was used in this research. Out of 305 referrals to the emergency room due to a suicide attempt, 100 reported drinking alcohol up to six hours before their attempt. Paired Matching and Usual Frequency were employed to analyze the data with STATA 12.0. The probability of attempting suicide up to six hours after drinking alcohol appeared increased by 27 times (95% CI: 8.1-60.4). Separate analysis for each of these hours from the first to the sixth hour after alcohol use was also performed. Fifty percent of attempted suicides happened one hour after alcohol use. Relative risk for the first and second hour was 10% and 5% respectively. Alcohol use is a strong proximal risk factor for attempted suicide among Iranian subjects. Prevention of alcohol use should be considered in setting up of the national Suicide attempt prevention program.

Single nucleotide polymorphisms in the BDNF gene and suicide in the Slovenian sample

In recent years, brain-derived neurotrophic factor (BDNF) and sequence variations within and near the BDNF gene have been studied for associations with various psychiatric disorders, including suicidal behavior. Since our previous work on completed suicide in Slavic population showed an association of the functional single nucleotide polymorphism (SNP) rs6265 in the BDNF gene, we decided to extend the investigation and test additional SNPs in the BDNF gene, rs7124442, rs10767664, rs962369, rs12273363, rs908867, rs1491850, and rs1491851, for association with completed suicide. Our study subjects were Caucasians, and included 486 suicide completers and 289 controls. The case/control comparisons of allele, genotype and haplotype frequency distributions were performed by means of Pearson's X(2) tests. Analyses of allele and genotype frequency distributions of the sudied SNPs did not reveal any significant differences between the controls and suicide completers. Haplotype analysis (rs7124442-rs10767664-rs962369-rs12273363-rs908867) showed an association of the haplotype C-A-T-C-C (p(corr)=0.038) with completed suicide, indicating that these SNPs on a haplotype level may play a role in completed suicide phenotype in our study sample.

Heavy alcohol use and suicidal behavior among people who use illicit drugs: A cohort study

BACKGROUND

People who use illicit drugs (PWUD) are known to experience high rates of suicidal behavior. While heavy alcohol use has been associated with suicide risk, its impact on the suicidal behavior of PWUD has not been well characterized. Therefore, we examined the relationship between heavy alcohol use and suicidal behavior among PWUD in Vancouver, Canada.

METHODS

Data are derived from two prospective cohort studies of PWUD in Vancouver, Canada, from 2005 to 2013. Participants completed questionnaires that elicited information regarding sociodemographics, drug use patterns, and mental health problems, including suicidal behavior. We used recurrent event survival analyses to estimate the independent association between at-risk/heavy drinking (based on National Institute of Alcohol Abuse and Alcoholism [NIAAA] criteria) and risk of incident, self-reported suicide attempts.

RESULTS

Of 1757 participants, 162 participants (9.2%) reported 227 suicide attempts over the 8-year study period, resulting in an incidence rate of 2.5 cases per 100 person-years. After adjusting for potential confounders, including intensive illicit drug use patterns, heavy alcohol use (adjusted hazard ratio [AHR] = 1.97; 95% confidence interval [CI] = 1.39, 2.78) was positively associated with an increased risk of suicidal behavior.

CONCLUSIONS

We observed a high burden of suicidal behavior among a community-recruited sample of PWUD. Heavy alcohol use predicted a higher risk of suicide attempt, independent of other drug use patterns. These findings demonstrate the need for evidence-based interventions to address suicide risk among PWUD, particularly those who are heavy consumers of alcohol.

Supportive text messages to reduce mood symptoms and problem drinking in patients with primary depression or alcohol use disorder: protocol for an implementation research study

BACKGROUND

Depression and Alcohol Use Disorders (AUDs) are two leading causes of disability worldwide and are associated with significant treatment challenges requiring new, innovative, cost-effective and technologically-based therapies including the use of supportive text messages.

OBJECTIVE

To determine the feasibility and effectiveness of supportive text messages in long-term follow-up to reduce mood symptoms and problem drinking in patients with Depression or AUD respectively and to explore the usefulness of self-reports of health services utilization as an outcomes measure.

METHODS

This will be a longitudinal, prospective, parallel-design, two-arm, placebo-controlled single-rater-blinded randomized clinical trial with a recruitment period of 6 months and an observation period of 12 months for each participant, with two strata based on primary diagnosis of Major Depressive Disorder or AUD. The sample size will be 120, with about 60 patients randomized from each primary diagnostic grouping. Patients in all intervention groups will receive twice-daily supportive SMS text messages for 3 months and then daily supportive text messages for the next three months. Patients will also receive a phone call every two weeks from the research assistant assigning treatment allocation to confirm that they are still receiving the text messages and to thank them for taking part in the study. Patients in the control group will receive no text messages but will also receive a phone call from the same research assistant every two weeks to thank them for taking part in the study.

RESULTS

The study starts in April 2015 and ends in September 2016. It is envisaged that both qualitative and quantitative primary and secondary outcomes, including patient perceptions of the intervention, will shed light on the feasibility of using automated supportive text message interventions in long term for patients with Depression and AUD. This will inform a full-scale clinical trial.

CONCLUSIONS

The paradigm for behavior change using text messages as a patient-direct intervention is consistent with a cognitive behavior therapy approach and addictions counselling principles. Given the automaticity of the messages, we anticipate that if the intervention proves successful, it will represent a low cost strategy that will be readily available and can bring relief to patients in hard-to-reach areas with limited access to psychological therapies.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02327858; https://clinicaltrials.gov/ct2/show/NCT02327858 (Archived by WebCite at https://clinicaltrials.gov/ct2/show/NCT02327858).

A modelling tool for policy analysis to support the design of efficient and effective policy responses for complex public health problems

Background

In the design of public health policy, a broader understanding of risk factors for disease across the life course, and an increasing awareness of the social determinants of health, has led to the development of more comprehensive, cross-sectoral strategies to tackle complex problems. However, comprehensive strategies may not represent the most efficient or effective approach to reducing disease burden at the population level. Rather, they may act to spread finite resources less intensively over a greater number of programs and initiatives, diluting the potential impact of the investment. While analytic tools are available that use research evidence to help identify and prioritise disease risk factors for public health action, they are inadequate to support more targeted and effective policy responses for complex public health problems.

Discussion

This paper discusses the limitations of analytic tools that are commonly used to support evidence-informed policy decisions for complex problems. It proposes an alternative policy analysis tool which can integrate diverse evidence sources and provide a platform for virtual testing of policy alternatives in order to design solutions that are efficient, effective, and equitable. The case of suicide prevention in Australia is presented to demonstrate the limitations of current tools to adequately inform prevention policy and discusses the utility of the new policy analysis tool.

Summary

In contrast to popular belief, a systems approach takes a step beyond comprehensive thinking and seeks to identify where best to target public health action and resources for optimal impact. It is concerned primarily with what can be reasonably left out of strategies for prevention and can be used to explore where disinvestment may occur without adversely affecting population health (or equity). Simulation modelling used for policy analysis offers promise in being able to better operationalise research evidence to support decision making for complex problems, improve targeting of public health policy, and offers a foundation for strengthening relationships between policy makers, stakeholders, and researchers.

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.