Acute alcohol use and suicidal behavior: a review of the literature

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Baclofen in the treatment of alcohol use disorder: tailored doses matter

AIMS

To address the question of tailored baclofen prescribing in alcohol use disorder (AUD) in relation to dose-dependent efficacy and the potential danger of high doses and to provide suggestions for the use of high doses of baclofen in the treatment of AUD. The context is the approvement in France of baclofen in the treatment of AUD without dose limitation, making French physicians, who usually prescribe baclofen in a tailored manner, often use high or very high doses.

METHODS

A narrative review of the results of randomized controlled trials (RCTs) and observational studies that used tailored baclofen prescribing and of the severe adverse effects of baclofen that have been reported in the literature.

RESULTS

The results show that RCTs using tailored doses of baclofen in AUD are not completely demonstrative, though they are encouraging according to certain meta-analyses, while observational studies that used tailored doses constantly show a good effectiveness of baclofen treatment. The results suggest that many severe adverse effects of baclofen could be related to a nonrespect by physicians of prescription rules and appropriate treatment monitoring.

CONCLUSIONS

The use of tailored doses shows that the dose required to suppress cravings is highly variable, low or high, depending on each case. Analysis of the circumstances in which severe adverse effects occur suggest that a careful monitoring of baclofen prescribing might prevent a large majority of severe adverse effects. We propose that the education of the patients and the prescription skills, seriousness, and availability of the prescribing physicians are of major importance in the managing of tailored baclofen treatment of AUD.

Prevalence of Alcohol and Other Drug Use in Patients Presenting to Hospital for Violence-Related Injuries: A Systematic Review

Substance use is a risk factor for being both a perpetrator and a victim of violence. The aim of this systematic review was to report the prevalence of acute pre-injury substance use in patients with violence-related injuries. Systematic searches were used to identify observational studies that included patients aged ≥15 years presenting to hospital after violence-related injuries and used objective toxicology measures to report prevalence of acute pre-injury substance use. Studies were grouped based on injury cause (any violence-related, assault, firearm, and other penetrating injuries including stab and incised wounds) and substance type (any substance, alcohol only, drugs other than alcohol only), and they were summarized using narrative synthesis and meta-analyses. This review included 28 studies. Alcohol was detected in 13%-66% of any violence-related injuries (five studies), 4%-71% of assaults (13 studies), 21%-45% of firearm injuries (six studies; pooled estimate = 41%, 95% CI: 40%-42%, n = 9,190), and 9%-66% of other penetrating injuries (nine studies; pooled estimate = 60%, 95% CI: 56%-64%, n = 6,950). Drugs other than alcohol were detected in 37% of any violence-related injuries (one study), 39% of firearm injuries (one study), 7%-49% of assaults (five studies), and 5%-66% of penetrating injuries (three studies). The prevalence of any substance varied across injury categories: any violence-related injuries = 76%-77% (three studies), assaults = 40%-73% (six studies), firearms = n/a, other penetrating injuries = 26%-45% (four studies; pooled estimate = 30%, 95% CI: 24%-37%, n = 319).Overall, substance use was frequently detected in patients presenting to hospital for violence-related injuries. Quantification of substance use in violence-related injuries provides a benchmark for harm reduction and injury prevention strategies.

Suicide victims and alcohol-related consumption in Brazil: An observational study and a narrative review of the literature

Deaths due to external causes, mainly suicide, are a severe public health problem in Brazil. Evidence shows that the tendency to impulsive behavior is exacerbated after alcohol consumption. The relationship between alcohol and suicide is poorly described in the medical literature. The study aims to analyze the relationship between victims' blood alcohol levels and suicides in some municipalities in Greater São Paulo, Brazil. We reviewed the data from the medical records of 805 necropsies performed at the Medical Legal Institute of Sao Paulo in Franco da Rocha, Brazil, from 2001 to 2017. The manner of death was established based on the result of police inquiry. Deaths due to suicide (n=41) were selected for the study. Descriptive statistics and Student t-test was applied when appropriate. The variables studied were sex, age, suicide mechanism, and blood alcohol level (BAC). In all cases we could not determine how much time the deceased consumed alcohol before suicide. Of the individuals analyzed, 85.36% were male, and 14.64% were female. The most prevalent age range for males was between 18 and 23 (19.5%). For females, it was between 12 and 23 years (33.2%). Most suicides (48.78%) were due to hanging, followed by self-poisoning (22.08%) and firearms (17.1%). 38 victims (92.68%) presented a positive BAC, over 0.3 mg/dl. The higher levels were in the group of suicide by hanging (2.3 mg/ml). Thus, alcohol intoxication is common among suicide victims, and it can contribute to the fatal outcome as a risk factor. Further studies are necessary for a better comprehension of the effect of alcohol on suicide victims.

Sexual Assault, Posttraumatic Stress, Alcohol Use, and Suicidality Among Diverse College Students

Suicide is the second leading cause of death among college-aged populations. This study examined the association of demographics (sexual orientation, gender identity, age, and race), sexual assault, posttraumatic stress symptoms (PTSS), and alcohol use with suicidality, current urge to self-harm, and current suicidal intent among a diverse sample of college students (n = 2,160) from two universities. Over half of participants reported any suicidality (63.5%), 12% reported current urge to harm themselves, and 5% reported current suicidal intent. A linear regression indicated that participants who identified as a sexual minority, gender minority, consumed more drinks per week, and had more severe PTSS reported higher levels of suicidality. University also was associated with suicidality. A negative binomial regression demonstrated that participants who identified as a sexual minority and had more severe PTSS had more current urge to harm themselves. Further, a negative binomial regression demonstrated that first-generation college students, students with more severe sexual assault histories, and students with more severe PTSS had higher current suicidal intent. Findings suggest that risk factors may differ for college students' general suicidality, self-harm urges, and suicidal intent, suggesting that these may be separate constructs. More comprehensive models, incorporating multiple risk factors and multiple ways of assessing suicidality, are needed to better understand the range of college student suicidal behavior and risks.

Analysis of veterans crisis line data: Temporal factors associated with the initiation of emergency dispatches

PURPOSE

To identify temporal patterns of emergency dispatches as initiated by Veteran Crisis Line (VCL) responders and among moderate- and high-risk contacts.

METHODS

Incidence rate ratios (IRRs) were used to examine the incidence of emergency dispatches among all 1,437,543 VCL contacts across 2019-2020.

RESULTS

Emergency dispatches were initiated in 57,077 (4.0%) contacts. IRRs were elevated during Labor Day, IRR (95% CI) = 1.33 (1.15-1.54), and Independence Day, IRR (95% CI) = 1.22 (1.05-1.43), weekends, Saturdays, IRR (95% CI) = 1.04 (1.01-1.08), Sunday (reference), and 6 pm to 11:59 pm, IRR (95% CI) = 1.06 (1.04-1.09). IRRs for moderate- and high-risk contacts were higher on Memorial Day, IRR (95% CI) = 1.16 (1.00-1.33), Sunday (reference), and 6 pm to 11:59 pm (reference).

CONCLUSIONS

The initiation of emergency dispatches fluctuates over time and were highest during Labor Day and Independence Day, weekends, and evenings. Moderate- and high-risk contact also fluctuate over time and were highest on Memorial Day, Sundays, and midnight to 5:59 am. VCL policy makers can use knowledge of temporal fluctuations to allocate public health resources for increased efficiency and greatest impact; however, additional research on temporal stability and generalizability is needed.

Untangling the temporal association between daily urges to die by suicide and to use substances

The current study examined the potential bi-directional associations between urges to die by suicide and to use alcohol or drugs as well as sadness and anger in relation to these urges. Forty individuals with suicidal thoughts, binge drinking behaviors, and emotion regulation difficulties, who were recruited for a clinical trial of internet-delivered Dialectical Behavior Therapy skills training, completed daily diaries on suicide and substance use urges and emotions over twenty-one days. Results indicated that higher daily peak substance use urges were associated with a greater likelihood of reporting suicide urges on the next day. Participants with higher and an increase in peak substance use urges (relative to their daily average) were both more likely to report suicide urges on the same day. Furthermore, both daily peak sadness and anger ratings predicted next-day suicide urges while accounting for substance use urges, though sadness may be a stronger predictor. These findings suggested a possible unidirectional pathway from urges to use substances to subsequent urges to die by suicide and a unique role of sadness.

Significantly elevated phosphatidylethanol levels in recent suicide attempters, but not in depressed controls and healthy volunteers

INTRODUCTION

Suicide is a complex transdiagnostic phenomenon. It is strongly associated with, but not exclusive to major depressive disorder (MDD). Hazardous alcohol drinking has also been linked to an increased risk of suicidal behaviours, however, it is often underreported. The study aimed to evaluate whether an objective measure of chronic alcohol use, phosphatidylethanol (PEth) could be useful as a biomarker in clinical practice.

METHOD

ology. The present case-control multi-centric study recruited 156 participants into three study groups: 52 patients treated for major depressive disorder (MDD), 51 individuals immediately following a suicide attempt (SA), and 53 volunteers. Sociodemographic data, medical history, and laboratory data, including PEth concentrations and C-reactive protein levels, were collected from study participants.

RESULTS

PEth concentrations were the highest in suicide attempters (232,54 ± 394,01 ng/ml), followed by patients with MDD (58,39 ± 135,82 ng/ml), and the control group (24,45 ± 70,83 ng/ml) (Kruskall Wallis χ2 = 12.23, df = 2, p = .002). In a multinomial logistic regression model with adjustments, PEth concentration was able to predict belonging to suicide attempters' group, but not to depression group (p = .01). Suicide attempters were also more likely to underreport their recent alcohol consumption.

LIMITATIONS

We did not analyze SA methods, psychiatric comorbidity and several other factors that might be associated with PEth levels, such as body mass index, race, and haemoglobin levels. Sample recruited in hospital settings may not be representative of the whole population. The results of this adult-only study cannot be generalized to adolescents.

CONCLUSIONS

PEth levels in recent suicide attempters significantly exceeded those of patients with MDD and controls. Suicide attempters also were more likely to underreport their alcohol consumption when questioned about their consuption. PEth might be an interesting biomarker to evaluate individuals at risk of SA.

Food-restricted alcohol consumption: relation to psychopathology in college students

Objective: Food-restricted alcohol consumption (FRAC) is a growing concern among college students. We investigated demographic and lifestyle characteristics and psychiatric symptoms associated with FRAC. Participants: College students (n = 561) at a large southeastern university in the United States. Methods: Participants completed online self-reported questionnaires assessing past-year FRAC, demographic and lifestyle characteristics, and psychiatric symptoms. Results: The past-year prevalence of FRAC was 23.89%. In the bivariate analyses, students engaging in FRAC had higher mean scores of multiple psychiatric symptoms, reported more harmful or hazardous drinking and suicidality, and were more likely to report a history of an eating disorder than their peers without FRAC. In a hierarchical regression model, binge eating, cognitive restraint, self-reported history of an eating disorder, and harmful or hazardous drinking were significantly associated with FRAC (ps < 0.05) after other psychiatric symptoms were included in the model. Conclusion: Our findings stress the importance of heightened awareness of FRAC in college.

Dexamethasone therapy prevents delayed neuropsychiatric sequelae after carbon monoxide poisoning: a prospective registry-based study

BACKGROUND

Delayed neuropsychiatric sequelae are major complications of carbon monoxide poisoning; carbon monoxide triggers brain oxidation and inflammation. Corticosteroids such as dexamethasone modulate neurological damage after carbon monoxide poisoning through anti-inflammatory actions and immune response inhibition. However, it is not known whether corticosteroids prevent delayed neuropsychiatric sequelae. We thus studied whether dexamethasone reduced the incidence of delayed neuropsychiatric sequelae.

METHODS

This registry-based study enrolled patients with carbon monoxide poisoning treated in a Korean tertiary care hospital from March 1^st, 2020 to November 30^th, 2021. Data of patients were prospectively collected during the study period, and retrospectively analyzed. One group received intravenous dexamethasone. We performed multivariable logistic regression analysis to identify factors associated with delayed neuropsychiatric sequelae.

RESULTS

A total of 128 patients were enrolled, of which 99 patients received dexamethasone therapy and 29 patients did not. The incidences of delayed neuropsychiatric sequelae in the dexamethasone and non-dexamethasone groups were 16.2% and 37.9%, respectively. Multivariable logistic regression analysis revealed that dexamethasone use (odds ratio = 0.122, 95% confidence interval 0.031-0.489) and a higher Glasgow Coma Scale (odds ratio = 0.818, 95% confidence interval 0.682-0.981) was associated with a lower incidence of delayed neuropsychiatric sequelae.

CONCLUSION

Early dexamethasone treatment was significantly associated with a decreased incidence of delayed neuropsychiatric sequelae. A higher Glasgow Coma Scale at presentation also was associated with a lower incidence of delayed neuropsychiatric sequelae.

The association between reattempted suicide and incoming calls to the brief contact intervention service, VigilanS: a study of the clinical profile of callers

BACKGROUND

Suicide is a major health problem globally. As attempted suicide is a major risk factor for suicide, specific prevention strategies have been designed for use thereafter. An example is the brief contact intervention (BCI). In this regard, France employs a composite BCI, VigilanS, which utilizes three types of contact: phone calls, postcards and a 'who to contact in a crisis' card. Previous studies have found that this system is effective at preventing suicide. Nevertheless, VigilanS was not effective in the same way for all the patients included. This observation raises the question of specific adaptation during follow-up for populations that were less receptive to the service. In consideration of this issue, we identified one study which found that incoming calls to the service were linked with a higher risk of suicide reattempts. However, this study did not document the profiles of the patients who made these calls. Better understanding of why this population is more at risk is important in terms of identifying factors that could be targeted to improve follow-up. This research therefore aims to bring together such data.

METHODS

We performed a retrospective analysis of 579 patients referred to VigilanS by Toulouse University Hospital (France). We examined the sociodemographics, clinical characteristics, and follow-ups in place and compared the patients who made incoming calls to the service versus those who did not. Subsequently, we conducted a regression analysis using the significantly associated element of patients calling VigilanS. Then, in order to better understand this association, we analyzed the factors, including such calls, that were linked to the risk of suicide reattempts.

RESULTS

We found that 22% of the patients in our sample called the VigilanS service. These individuals: were older, at 41.4 years versus 37.9 years for the non-callers; were more likely to have a borderline personality disorder (BPD) diagnosis (28.9% versus 19.3%); and had a history of suicide attempts (71.9% versus 54.6%). Our analysis confirmed that incoming calls to VigilanS (OR = 2.9) were associated with reattempted suicide, as were BPD (OR = 1.8) and a history of suicide attempts (OR = 1.7).

CONCLUSION

There was a high risk that the patients calling VigilanS would make another suicide attempt. However, this association was present regardless of the clinical profile. We postulate that this link between incoming calls and reattempted suicide may arise because this form of contact is, in fact, a way in which patients signal that a further attempt will be made.

Alcohol use and the gender-specific risk of suicidal behavior: a systematic review and meta-analysis protocol

BACKGROUND

Alcohol use is an important risk factor for suicidal behavior, with a heightened risk found among women. The objective of this study is to determine the gender-specific risk of suicidal behaviors (suicide attempt and death by suicide) for different levels and dimensions of alcohol use-i.e., for (1) average alcohol volume consumed, (2) binge drinking, and (3) individuals with an alcohol use disorder.

METHODS

We will systematically search the available literature for primary studies on the risk relationships specified above. Using a predetermined set of keywords, a comprehensive systematic literature search will be conducted in the following electronic databases: Embase, PsycINFO, PubMed, and Web of Science. The basic inclusion criteria will be (1) an original, quantitative (cohort, case-control or cross-sectional) study; with (2) a measure of risk of at least one dimension of our alcohol exposures in relation to at least one of our outcomes of interest (suicide attempt or death by suicide), and its corresponding measure of variability is reported (or sufficient data to calculate these); and (3) estimates of risk stratified by gender. Studies (1) that use only qualitative labels of alcohol use, and (2) where suicide attempt and non-suicidal self-harm cannot be disaggregated will be excluded. There will be no restrictions on language, geographical region, or year of publication. Two reviewers will independently perform the search and systematic assessment of each identified study and subsequent extraction of data. Categorical random-effects meta-analyses will be conducted to obtain gender-specific pooled risk estimates. Risk of bias will be assessed using the Risk of Bias In Non-randomised Studies-of Interventions tool and the Grading of Recommendations Assessment, Development and Evaluation approach will be used to rate the quality of evidence.

DISCUSSION

This study will synthesize all available data on the gender-specific relationship between various dimensions of alcohol use and suicidal behavior simultaneously in a coherent framework. We will provide risk estimates with the detail needed to better understand the respective risk relationships and appreciate the burden of alcohol-attributable suicide.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022320918.

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 ideation and attempt and associated factors among patients with substance use disorder: institution-based cross-sectional study

BACKGROUND

No published research in Ethiopia has examined the prevalence of suicidal ideation and suicide attempts and associated factors among patients with substance use disorder.

AIMS

The main aim of this study was to assess the prevalence of suicidal ideation, suicide attempt and associated factors among patients with substance use disorders.

METHOD

An institution-based cross-sectional study was conducted from 5 May to 13 June 2019 in Addis Ababa. A total of 408 patients were identified using a systematic sampling technique. Data were collected through interviews using the suicidality module of the Composite International Diagnostic Interview. Data were entered into EpiData and analysed using SPSS. Logistic regression analyses were employed. Variables with P < 0.05 were considered to be statistically significant with 95% confidence intervals.

RESULTS

Prevalence rates of suicidal ideation and attempt were found to be 39.5% and 18.6%, respectively. Family history of mental illness (adjusted odds ratio (AOR) = 3.60, 95% CI: 2.17, 5.97), comorbid mental illness (AOR = 3.61, 95% CI: 2.11, 6.16), perceived stigma related to substance misuse (AOR = 4.00, 95% CI: 2.26, 7.07) and alcohol use (AOR = 7.49, 95% CI: 1.99, 28.19) were associated with suicidal ideation. Being female (AOR = 2.46, 95% CI: 1.08, 5.70), family history of suicide (AOR = 3.08, 95% CI: 1.68, 5.64), comorbid mental illness (AOR = 4.09, 95% CI: 2.23, 7.49) and khat use (AOR = 3.73, 95% CI: 1.24, 11.17) were associated with suicide attempt.

CONCLUSIONS

The prevalence of suicidal ideation and attempt were both found to be high. In particular, patients who had a comorbid mental illness were at high risk of both suicidal ideation and attempt. Therefore, special attention should be given to those with a family history of suicide or comorbid mental illness.

Development of a Checklist for Predicting Suicidality Based on Risk and Protective Factors: The Gwangju Checklist for Evaluation of Suicidality

OBJECTIVE

The aim of the study was to develop a checklist for mental health clinicians to predict and manage suicidality.

METHODS

A literature review of the risk and protective factors for suicide was conducted to develop a checklist for evaluating suicidality.

RESULTS

The fixed risk factors included sex (male), age (older individuals), history of childhood adversity, and a family history of suicide. Changeable risk factors included marital status (single), economic status (poverty), physical illness, history of psychiatric hospitalization, and history of suicide attempts. Recent discharge from a mental hospital and a recent history of suicide attempts were also included. Manageable risk factors included depression (history and current), alcohol problems (frequent drinking and alcohol abuse), hopelessness, agitation, impulsivity, impaired reality testing, and command hallucinations. Protective factors included responsibility to family, social support, moral objections to suicide, religiosity, motivation to get treatment, ability to cope with stress, and a healthy lifestyle. A final score was assigned based on the sum of the risk and protective factor scores.

CONCLUSION

We believe that the development of this checklist will help mental health clinicians to better assess those at risk for suicidal behavior. Further studies are necessary to validate the checklist.

Suicidal ideation and sobriety: Should acute alcohol intoxication be taken into account for psychiatric evaluation?

BACKGROUND

When evaluating an emergency department (ED) patient who presents with suicidal ideation, it is a common practice to wait until the patient's ethanol level is known or calculated to be less than 80 mg/dl to evaluate patient safety. We know of no study that establishes an association between the degree of alcohol intoxication based on a blood alcohol level (BAL) and reported suicidal ideation (SI) upon recovery.

METHODS

We conducted a retrospective review of patients evaluated in a Midwestern ED for the calendar year 2017. Cases were selected if they had a psychiatric social work consult and a blood alcohol level drawn while in the ED. Patients were selected on the same 2 days each week throughout the year to meet the sample size requirements of the study, resulting in 1084 cases for review. Chi-square analysis was used to evaluate the relationship between suicidal ideation and alcohol intoxication as defined by a BAL ≥80 mg/dl.

RESULTS

Among patients presenting with suicidal ideation and a concurrent BAL ≥80 mg/dl, 69% no longer reported suicidal ideation when their BAL was <80 mg/dl, compared to 38% for patients without a positive BAL on presentation (chi-square, p = 0.000012).

CONCLUSION

Our data show that patients presenting to the ED with complaints related to suicidal behavior who have a BAL ≥80 mg/dl are more likely to no longer endorse having suicidal ideation once their BAL is < 80 mg/dl than patients with similar presenting complaints and no alcohol intoxication. This finding supports the common ED practice of re-assessing suicidal ideation among individuals who are initially intoxicated once their BAL has decreased below 80 mg/dl.

Working out dads (WOD): a study protocol for a randomised controlled trial of a group-based peer support intervention for men experiencing mental health difficulties in early fatherhood

BACKGROUND

Approximately one in ten men experience mental health difficulties during the early years of fatherhood, and these can have negative impacts on children and families. However, few evidence-based interventions targeting fathers' mental health are available. The aim of the trial is to evaluate the effectiveness and cost-effectiveness of Working Out Dads (WOD) - a facilitated peer support group intervention for fathers of young children, in reducing psychological distress and other mental health symptoms.

METHODS

This trial will employ a parallel-arm randomised controlled trial (RCT) to evaluate the effectiveness and cost effectiveness of WOD peer support group intervention compared to usual care (a 30-min mental health and service focused phone consultation with a health professional). A total of 280 fathers of young children (aged 0-4 years) who are experiencing mental health difficulties and/or are at risk of poor mental health will be recruited. Randomisation and analyses will be at the level of the individual participant. The primary outcome is psychological distress symptoms, measured by the Kessler Psychological Distress Scale (K10) from baseline to 24 weeks post randomisation. A range of secondary outcomes will be assessed including suicidal ideation; mental health disorders, specific symptoms of depression, anxiety, and stress; social support, quality of life, health service use, and health care costs. Data will be collected at baseline, 10- and 24 weeks post-randomisation.

DISCUSSION

This trial will examine the effectiveness of a novel group-based peer support intervention in reducing the psychological distress and other mental health symptoms of fathers compared to usual care. The economic and process evaluation will guide policy decision making along with informing the future implementation of WOD on a larger scale if effectiveness is demonstrated.

TRIAL REGISTRATION

The current trial has been registered with ClinicalTrials.gov (Registration ID - NCT04813042 ). Date of Registration: March 22nd, 2021.

Suicide Risk and Protective Factors: A Network Approach

OBJECTIVE

Suicide is a complex phenomenon, with numerous factors contributing to an individual's risk of suicide. The aim of the present study was to explore how risk and protective factors for suicide interact with one another in a network sense and to determine which factors were most central to a network of these factors.

METHOD

Using an online survey, cross-sectional data were collected from a sample of 515 individuals who lived in New Zealand, Australia, the United Kingdom, and the United States of America. Participants were recruited through either social media or Prolific Academic. A network of 18 risk and protective factors for suicide was estimated using network analysis. Analyses were preregistered on the Open Science Framework.

RESULTS

Factors that had the highest strength centrality were feeling depressed, feeling hopeless, perceived burdensomeness, self-esteem, and social support. Factors that were directly associated with suicidal ideation included feeling depressed, perceived burdensomeness, feeling hopeless, self-esteem, resilience, access to mental health services and a positive attitude toward these services.

CONCLUSION

This research demonstrates the importance of examining protective factors as well as risk factors when estimating an individual's suicide risk. The results suggest that interventions targeting depression may be particularly beneficial in reducing suicide risk, but further longitudinal research is required.HIGHLIGHTSThe network analyses estimated depression to be the most central risk factor.Depression and perceived burdensomeness were risk factors for suicidal ideation.Self-esteem and resilience were protective against suicidal ideation.

Understanding suicidal pathways through the lens of a Dual-System Model of Suicidality in real-time: The potential of ecological momentary assessments

Within the ideation-to-action framework, existing theories of suicidal thoughts and behaviors (STBs) primarily focus on the linear progression of suicide risk. This, however, neglects growing evidence that many suicidal individuals do not experience their suicide attempt as a planned action, and in some instances deny even having experienced any suicidal thoughts. Furthermore, recent research has found that risk factors differ substantially between persons and that this is reflected in the variety of suicidal pathways. Considering the strong variability of STBs, new innovative theoretical concepts and assessment methods are needed to advance our understanding of multiple suicidal pathways. In this review, we apply a dual-system framework to suicidality, the Dual-System Model of Suicidality (DSMS), which accounts for two different systems of information processing and behavior. The first of these described is the reflective system, whereby STBs are viewed from a self-regulation perspective and thusly considered as maladaptive coping behavior to perceived discrepancies regarding important goals. Applying a feedback-based view such as this to STBs provides a deeper understanding into underlying psychological processes involved in the development of STBs. The second system described by the DSMS is the impulsive system. Here, STBs are seen as a maladaptive self-organizing pattern that gets activated in high-risk situations of acute stress, negative affect, and when resources of the reflective system are depleted. In this context, the DSMS is informed by a strength model of self-regulation, which assumes that self-regulation resources are limited, an aspect with important theoretical and clinical implications for the development of STBs. In order to demonstrate the theoretical and practical utility of the DSMS, this review draws mainly on studies using ecological momentary assessment (EMA), a technology that allows to investigate moment-to-moment changes in STBs, and is therefore well suited for capturing the complex interplay of self-regulatory and impulsive processes proposed by the DSMS. The application of a dual-system framework to suicide research represents an innovative and integrative approach for expanding our knowledge about fundamental processes and how their dynamics lead to STBs. The usefulness of the DSMS, implications for future suicide research with EMA, and clinical implications are discussed.

Sex-Specific Risk Profiles for Suicide Among Persons with Substance Use Disorders in Denmark

BACKGROUND AND AIMS

Persons with substance use disorders (SUDs) are at elevated risk of suicide death. We identified novel risk factors and interactions that predict suicide among men and women with SUD using machine learning.

DESIGN

Case-cohort study.

SETTING

Denmark.

PARTICIPANTS

The sample was restricted to persons with their first SUD diagnosis during 1995 to 2015. Cases were persons who died by suicide in Denmark during 1995 to 2015 (n = 2774) and the comparison subcohort was a 5% random sample of individuals in Denmark on 1 January 1995 (n = 13 179).

MEASUREMENTS

Suicide death was recorded in the Danish Cause of Death Registry. Predictors included social and demographic information, mental and physical health diagnoses, surgeries, medications, and poisonings.

FINDINGS

Persons among the highest risk for suicide, as identified by the classification trees, were men prescribed antidepressants in the 4 years before suicide and had a poisoning diagnosis in the 4 years before suicide; and women who were 30+ years old and had a poisoning diagnosis 4 years before and 12 months before suicide. Among men with SUD, the random forest identified five variables that were most important in predicting suicide; reaction to severe stress and adjustment disorders, drugs used to treat addictive disorders, age 30+ years, antidepressant use, and poisoning in the 4 prior years. Among women with SUD, the random forest found that the most important predictors of suicide were prior poisonings and reaction to severe stress and adjustment disorders. Individuals in the top 5% of predicted risk accounted for 15% of all suicide deaths among men and 24% of all suicides among women.

CONCLUSIONS

In Denmark, prior poisoning and comorbid psychiatric disorders may be among the most important indicators of suicide risk among persons with substance use disorders, particularly among women.

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.

Differentiating U.S. military veterans who think about suicide from those who attempt suicide: A population-based study

OBJECTIVE

Several vulnerability factors for suicidal behavior in U.S. veterans have been identified. However, little is known about factors that differentiate veterans who contemplate suicide from those who attempt suicide. This study examined sociodemographic and clinical characteristics that distinguish veterans who think about suicide from those who attempt suicide.

METHOD

Data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study, which surveyed a population-based sample of 4069 veterans. Analyses estimated the lifetime prevalence of suicide ideation (SI) and suicide attempts (SA); and examined differences between veterans with a history of attempt(s), and SI without a history of attempt(s).

RESULTS

A total 25.9% of U.S. veterans reported lifetime SI and 3.9% reported a SA. Several factors distinguished veterans with a history of SA from those with SI only: the strongest were younger age (odds ratio [OR] = 0.97, 95% CI = 0.95-0.98), nonsuicidal self-injury (OR = 1.81, 95% CI = 1.11-3.03), adverse childhood experiences (OR = 1.14; 95% CI = 1.06-1.23), alcohol use disorder (OR = 1.99; 95% CI = 1.28-3.12), lower household income (OR = 0.62; 95% CI = 0.40-0.95), and physical disability (OR = 1.69; 95% CI = 1.07-2.70).

CONCLUSIONS

Although a quarter of U.S. veterans contemplate suicide in their lifetimes, the majority do not attempt suicide. Specific sociodemographic and clinical features may differentiate veterans who contemplate versus attempt suicide.

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.

Substance Use Disorders (SUD) and Suicidal Behaviors in Adolescents: Insights From Cross-Sectional Inpatient Study

Objectives

To determine the demographic predictors of suicidal behaviors and measure the association between the spectrum of substance use disorders (SUD) and hospitalization for suicidal behaviors in the adolescent population.

Methods

We conducted a cross-sectional study using the nationwide inpatient sample and included 466,244 adolescent inpatients with psychiatric illnesses. The study sample was sub-grouped into suicidal (N = 182,454) and non-suicidal (N = 283,790) cohorts. The odds ratio (OR) of association for demographic characteristics and comorbid SUD in the suicidal group was evaluated using a logistic regression model witha P-value < 0.01.

Results

Our study population included 466,244 adolescent inpatients. Females had higher odds of suicidal behaviors (OR 1.45; 95% CI 1.431-1.470) compared to males. The most prevalent comorbid SUD among suicidal inpatients was cannabis (15.3%) but had a statistically non-significant association with suicidal behaviors (OR 0.98; 95% CI 0.95-0.99). Inpatients with alcohol use disorders had significantly increased odds of association with suicidal behaviors (OR 1.18; CI: 1.142-1.209) compare to other SUD. Among other substances (cannabis and stimulants), there existed a statistically non-significant association with hospitalization for suicidal behaviors.

Conclusion

Adolescent inpatients with comorbid alcohol use disorders were at 18% higher odds of hospitalization for suicidal behaviors. Our study provides a basis for more research while also suggesting potential avenues for early identification and intervention efforts for comorbid SUD in adolescents requiring psychiatric care to improve their prognosis and quality of life.

Alcohol-related suicide across Australia: a geospatial analysis

BACKGROUND

The acute effects of alcohol consumption are a major risk factor for suicide. Positive blood alcohol concentrations are present in almost one-third of all suicides at time of death. These suicides are defined as alcohol-related suicides. This cross-sectional study examines the geospatial distribution/clustering of high proportions of alcohol-related suicides and reports on socioeconomic and demographic risk factors.

METHODS

National Coronial Information System (NCIS) data were used to calculate proportions of suicides with alcohol present at the time of death for each level 3 statistical areas (SA3) in Australia. A density analysis and hotspot cluster analysis were used to visualise and establish statistically significant clustering of areas with higher (hotspots) and lower (coldspots) proportions. Subsequently, socioeconomic and demographic risk factors for alcohol use and suicide were reported on for hot and cold spots.

RESULTS

Significant clustering of areas with higher proportions of alcohol-related suicide occurred in northern Western Australia, the Northern Territory and Queensland, as well as inland New South Wales and inland Queensland. Clustering of SA3s with significantly lower proportions occurred in major city and inner regional Sydney and Melbourne. Conclusion and implications for public health: Results from this study identify areas in which prevention strategies should target alcohol use and can be used to inform prevention strategy design. Additionally, hotspots and coldspots identified in this study can be used for further analysis to better understand contextual risk factors for alcohol-related suicide.

Factors Predicting Acute Brain Injury in Cases of Carbon Monoxide Poisoning: A Prospective Registry-Based Study

Carbon monoxide (CO) is one of the most common poisoning substances worldwide. Since acute brain injury (ABI) is an important determinant of the neurological outcome in CO poisoning, screening for patients at a high risk of developing ABI is essential for the proper treatment. This study identified predictors of ABI in patients with CO poisoning. This prospective registry-based study was conducted in patients who visited a tertiary care hospital for CO poisoning from August 2016 to June 2020. ABI was defined as the presence of acute hypoxic lesions on diffusion-weighted magnetic resonance imaging. Multiple logistic regression analysis was performed to identify the predictors of ABI. Of 231 patients, 64 (27.7%) showed ABI. Multiple logistic regression analysis showed that a Glasgow Coma Scale (GCS) score <9 at presentation (odds ratio [OR] 3.28, 95% confidence interval (CI) 1.08–10.01), creatinine level >1.2 mg/dL (OR 3.04, 95% CI 1.16–8.01), and C-reactive protein (CRP) level >9.2 mg/L (OR 4.38, 95% CI 1.41–13.65) predicted ABI in cases of acute CO poisoning. In CO poisoning, the GCS score at presentation, and serum creatinine and CRP levels, were useful predictors of ABI, and may help clinicians identify high-risk patients for whom treatment should be prioritized.

Alcohol and cocaine use prior to suspected suicide: Insights from toxicology

INTRODUCTION

This study investigates whether there is a relationship between alcohol and cocaine use in deaths where suicide by self-injury is the suspected cause of death.

METHODS

Adults referred by coroners to the Imperial College London Toxicology Unit for toxicological analysis between 2012 and 2016 were reviewed for inclusion criteria. Those who died by self-injury reasoned to be deliberate were included in the analysis. Femoral blood alcohol concentration (BAC) and presence of cocaine or benzoylecognine (a metabolite of cocaine) in blood and/or urine were tabulated and odds ratios calculated.

RESULTS

A total of 1722 decedents met inclusion criteria. BAC was ≥50 mg/dL in 29% of decedents. Cocaine was detected in 8.4% of cases. The likelihood of testing positive for cocaine increased with BAC and was most frequent between 100 and 199 mg/dL, consistent with moderate to severe intoxication (odds ratio 5.88, 95% confidence interval 3.80, 9.09; P ≤ 0.001) compared to those with BAC <10 mg/dL.

DISCUSSION AND CONCLUSIONS

This study demonstrates a correlation between increasing BAC and likelihood of cocaine use prior to suspected suicide, up to a level consistent with severe intoxication. Cocaine use was found in a high proportion of cases relative to the general population reporting regular use. This pattern of drug and alcohol use has previously been given little attention in suicide prevention strategies and clinical prioritisation.

Suicide Risk and Addiction: The Impact of Alcohol and Opioid Use Disorders

Purpose of Review

Suicide is a major public health concern and a leading cause of death in the US. Alcohol and opioid use disorders (AUD/OUD) significantly increase risk for suicidal ideation, attempts, and death, and are the two most frequently implicated substances in suicide risk. We provide a brief overview of shared risk factors and pathways in the pathogenesis of AUD/OUD and suicidal thoughts and behaviors. We also review clinical recommendations on inpatient care, pharmacotherapy, and psychotherapeutic interventions for people with AUD/OUD and co-occurring suicidal ideation and behavior.

Recent Findings

Among people with an underlying vulnerability to risk-taking and impulsive behaviors, chronic alcohol intoxication can increase maladaptive coping behaviors and hinder self-regulation, thereby increasing the risk of suicide. Additionally, chronic opioid use can result in neurobiological changes that lead to increases in negative affective states, jointly contributing to suicide risk and continued opioid use. Despite significantly elevated suicide risk in individuals with AUD/OUD, there is a dearth of research on pharmacological and psychosocial interventions for co-occurring AUD/OUD and suicidal ideation and behavior.

Summary

Further research is needed to understand the effects of alcohol and opioid use on suicide risk, as well as address notable gaps in the literature on psychosocial and pharmacological interventions to lower risk for suicide among individuals with AUD/OUD.

Reporting of alcohol as a contributor to death in Australian national suicide statistics and its relationship to post-mortem alcohol concentrations

AIM

To describe the assignment of International Classification of Disease (ICD)-10 alcohol codes as underlying or contributory causes of death by the Australian Bureau of Statistics during mortality coding for suicides according to the blood alcohol concentration (BAC) detected at autopsy.

DESIGN

Population-based case-series descriptive analysis.

SETTING AND PARTICIPANTS

Data for all alcohol-related (Alc+) suicide deaths (aged 15+) in Australia from 2010-2015 (n = 3132) from the National Coronial Information System.

MEASUREMENTS

Alc+ suicides were categorised as those with a post-mortem BAC ≥0.05 g/100 mL. The outcome variable was whether the case was assigned an ICD-10 alcohol code (F10.0-F10.9, R78.0, T51, X45 and/or X65). We estimated OR for the assignment of codes in Alc+ suicides using BAC as the key predictor. We also examined several covariates that have been implicated in the risk of Alc+ suicides.

FINDINGS

An ICD-10 alcohol code was assigned during the mortality coding process in 47.6% (n = 1491) of Alc+ suicides. Higher BAC was associated with higher odds of having a code assigned; cases with a BAC over 0.20 g/100 mL over were twice as likely to have an alcohol code assigned (adjusted OR [AOR] = 2.06, 95% CI = 1.59, 2.67) compared with cases with a BAC of 0.050-0.075 g/100 mL. Compared with New South Wales, higher likelihood of code assignment was found in Northern Territory (AOR = 3.85, 95% CI = 2.32, 6.63) and Western Australia (AOR = 2.89, 95% CI = 2.27, 3.68). Compared with 15-24 year olds, 25-44 (AOR = 0.79, 95% CI = 0.63, 0.99) and 65-84 year olds (AOR = 0.63, 95% CI = 0.43, 0.93) were less likely to have a code assigned.

CONCLUSIONS

An ICD-10 alcohol code was not assigned as an underlying or contributory cause of death in over half of suicides in Australia (2010-2015) with a BAC ≥0.05 g/100 mL. The higher the BAC detected at autopsy, the more likely cases were to be assigned an alcohol code during the mortality coding process.

An implementation evaluation of "Zero Suicide" using normalization process theory to support high-quality care for patients at risk of suicide

Background

Suicide rates continue to rise across the United States, galvanizing the need for increased suicide prevention and intervention efforts. The Zero Suicide (ZS) model was developed in response to this need and highlights four key clinical functions of high-quality health care for patients at risk of suicide. The goal of this quality improvement study was to understand how six large health care systems operationalized practices to support these functions-identification, engagement, treatment and care transitions.

Methods

Using a key informant interview guide and data collection template, researchers who were embedded in each health care system cataloged and summarized current and future practices supporting ZS, including, (1) the function addressed; (2) a description of practice intent and mechanism of intervention; (3) the target patient population and service setting; (4) when/how the practice was (or will be) implemented; and (5) whether/how the practice was documented and/or measured. Normalization process theory (NPT), an implementation evaluation framework, was applied to help understand how ZS had been operationalized in routine clinical practices and, specifically, what ZS practices were described by key informants (coherence), the current state of norms/conventions supporting these practices (cognitive participation), how health care teams performed these practices (collective action), and whether/how practices were measured when they occurred (reflexive monitoring).

Results

The most well-defined and consistently measured ZS practices (current and future) focused on the identification of patients at high risk of suicide. Stakeholders also described numerous engagement and treatment practices, and some practices intended to support care transitions. However, few engagement and transition practices were systematically measured, and few treatment practices were designed specifically for patients at risk of suicide.

Conclusions

The findings from this study will support large-scale evaluation of the effectiveness of ZS implementation and inform recommendations for implementation of high-quality suicide-related care in health care systems nationwide.

Combined Associations of Smoking and Bullying Victimization With Binge Drinking Among Adolescents in Beijing, China

Background: Binge drinking and smoking among adolescents are serious public concerns. However, very few studies have explored the reinforcement of bullying victimization by such behavior. Our study aimed at examining the individual and combined associations of smoking and bullying victimization with binge drinking among adolescents in Beijing, China. Methods: A total of 33,694 students aged 13-17 years old in Beijing, China were anonymously investigated via the cross-sectional Chinese Youth Risk Behavior Surveillance Survey from April to May 2014. A three-stage stratified sampling was used to select participants. Factors such as sociodemographic variables and indicators of smoking, bullying victimization, and binge drinking were analyzed with multiple logistic regressions, and joint and additive interaction effects were tested. Results: Overall, ever-drinking prevalence was 59.1% (boys: 64.4%; girls: 53.7%). Past 30-day binge drinking was 11.5% (boys: 15.6%; girls: 7.4%) and frequent binge drinking was 2.3% (boys: 3.3%; girls: 1.0%). Past 30-day smoking was 10.7% (boys: 16.4%; girls: 5.0%) and past 30-day bullying victimization was 48.7% (boys: 57.3%; girls: 40.1%). The combined effects of smoking and bullying victimization on occasional binge drinking (OR = 6.49, 95% CI = 5.60-7.52) and frequent binge drinking (OR = 10.32, 95% CI = 7.52-14.14) were significant, and the additive interaction effect was significant for current smoking and bullying victimization on frequent binge drinking (OR = 10.22, 95% CI = 9.43-11.07). The additive interaction effect for current smoking and bullying victimization on frequent binge drinking was significant among boys. Conclusion: Bullying victimization reinforced the association of smoking with frequent binge drinking, especially with findings specific to boys. Programs to prevent smoking or bullying or both may reduce binge drinking among adolescents in China.

Impact of Alcohol Policies on Suicidal Behavior: A Systematic Literature Review

Alcohol consumption has been found to be related to suicidal behavior at the individual and population level, but there is lack of literature reviews on the effect of alcohol policies on suicidal behavior. Therefore, the aim of the current study is to conduct a systematic literature review of the impact of alcohol policies at the population level on suicidal behavior and ideation. We searched the Cochrane CENTRAL, Cochrane DARE, EMBASE, Medline, ProQuest, PsycINFO, PubMed, SCOPUS, and Web of Science electronic databases in March 2019. Papers analyzing alcohol policies limiting alcohol use and studying suicidal behaviors as an outcome measure were included; we identified 19 papers. Although the methods and effect sizes varied substantially in the studies, reducing alcohol often led to reduction in suicidal behavior. Ecological-level studies predominantly investigated the effect of restrictions on alcohol availability and increased cost of alcohol, and the majority presented a reduction in suicides across Western and Eastern Europe, as well as the US. The majority of studies were rated as unclear risk of bias for a number of domains due to a lack of clear reporting. Policies targeting harmful alcohol consumption may contribute towards a reduction in suicidal behavior at the population level.

Predictors of Psychiatric Outpatient Adherence after an Emergency Room Visit for a Suicide Attempt

OBJECTIVE

This study aimed to investigate the potential correlation between baseline characteristics of individuals visiting an emergency room for a suicide attempt and subsequent psychiatric outpatient treatment adherence.

METHODS

Medical records of 525 subjects, who visited an emergency room at a university-affiliated hospital for a suicide attempt between January 2017 and December 2018 were retrospectively reviewed. Potential associations between baseline characteristics and psychiatric outpatient visitation were statistically analyzed.

RESULTS

107 out of 525 individuals (20.4%) who attempted suicide visited an outpatient clinic after the initial emergency room visit. Several factors (e.g., sober during suicide attempt, college degree, practicing religion, psychiatric treatment history) were significantly related to better psychiatric outpatient follow-up.

CONCLUSION

Several demographic and clinical factors predicted outpatient adherence following a suicide attempt. Therefore, additional attention should be given to suicide attempters who are at the risk of non-adherence by practitioners in the emergency room.

Coronavirus disease 2019 crisis and intentional injuries: now is not the time to erode alcohol control policies

In Canada, and elsewhere, the coronavirus disease 2019 (COVID-19) crisis has resulted in a social, economic, and alcohol policy environment that is likely to contribute to a rise in intentional injuries, whether interpersonal or self-directed violence. Heavy drinking has been identified as an important risk factor for intentional injuries, and with the erosion of alcohol control policies on alcohol availability, heavy drinking is likely to increase. During a time of social isolation, economic loss, psychological distress, and reduced access to health services and support networks, all of which are catalytic factors for both intentional injuries and heavy alcohol use, what is needed is individualized and population-based preventive interventions aimed at reducing alcohol consumption, rather than decisions to increase certain forms of alcohol availability.

Acute alcohol use in Australian coronial suicide cases, 2010-2015

BACKGROUND

Acute use of alcohol is a robust risk factor for suicide, reported in approximately one- to two-fifths of suicide cases. Comparisons of risk factors between suicides with and without prior acute alcohol consumption have not been investigated in Australia. This study addresses the gap by examining individual factors (age, sex, employment status, method of suicide) and environmental factors (month of death, jurisdiction) between alcohol and non-alcohol suicide.

METHODS

Data for all suicide deaths (aged 15 and over) in Australia were obtained from the National Coronial Information System (NCIS). Blood alcohol concentrations (BAC) were extracted from coronial reports, along with demographic information. Alcohol consumption prior to suicide was assumed if BAC ≥ 0.05 g/100 mL. We compared case characteristics between alcohol related and non-alcohol related suicides using logistic regression.

RESULTS

26.7% of suicide deaths in Australia had a BAC ≥ 0.05 g/100 mL. Alcohol use prior to suicide was associated with male gender (adjusted odds ratio [AOR]: 1.14, 95% confidence interval [95%CI]: 1.03, 1.26), being aged between 35-44 years (AOR: 1.26, 95%CI: 1.08, 1.46) and hangings (AOR: 1.53, 95%CI: 1.08, 1.46). Mean suicides per month over the timeframe demonstrated significant seasonality. Mean counts per month for alcohol related suicides peaked in December, compared to a peak in September for non-alcohol related suicides.

CONCLUSIONS

This study highlights differences between alcohol related and non-alcohol related suicides including sex, age, method of death, time of year and location within Australia. Targeting alcohol related suicide should be a key priority in comprehensive suicide prevention strategies.

Self-injurious behavior and gambling-related attitudes, perceptions and behaviors in adolescents

Gambling is prevalent among adolescents and adolescents are vulnerable to experiencing gambling-related problems. Although problem gambling and suicidal behavior have been linked in adults and self-injurious behaviors may predict future suicidality, prior studies have not investigated relationships between problem-gambling severity and self-injurious behavior in adolescents. Data from 2234 Connecticut high-school students were analyzed in chi-square tests and logistic regression models to examine self-injurious behaviors in relation to at-risk/problem gambling with respect to sociodemographic characteristics, gambling attitudes and perceptions, and extracurricular and health measures. Individuals who engaged in self-injurious behavior (versus those who did not) reported more permissive views towards gambling and were more likely to exhibit at-risk/problem gambling. Stronger relationships between problem-gambling severity and gambling in casinos (OR 4.85, 95%CI 1.94, 12.12) and non-strategic gambling (1.92, 95%CI 1.01, 3.66) were observed in adolescents who acknowledged engagement in self-injurious behavior versus those who did not. Links between self-injurious behaviors and more permissive gambling attitudes and perceptions and at-risk/problem gambling suggest the need for improved interventions targeting co-occurring self-injurious behaviors and gambling. Stronger relationships between problem-gambling severity and casino and non-strategic gambling among adolescents with self-injurious behaviors suggest adolescents with self-injurious behavior may engage in specific forms of gambling as maladaptive coping strategies to alleviate suffering. Prevention and treatment approaches targeting distress management and improving adaptive coping skills may be important for targeting self-injurious behaviors in adolescents with at-risk/problem gambling.

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

Background

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

Methods

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

Results

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

Conclusions

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

Alcohol use and risk of suicide: a systematic review and Meta-analysis

Objectives: Alcohol use has several consequences and is one of the variables that increase risk of suicide. This meta-analysis was performed using cohort studies to clarify the association of alcohol use and suicide.Method: Scientific sources were reviewed regarding the keywords. After screening, thirty cohort studies were identified for the meta-analysis. The analysis was performed based on the random effects and subsequent analysis of the subgroups, based on various variables.Result: Analysis of the results showed that there is a relationship between alcohol use and suicide. Risk Ratio (RR) between alcohol use and suicide was 1.65. In men, pooled RR was 1.56 with 95% CI = 1.20-2.03, and in women, the pooled RR was equal to 1.40 with 95% CI = 1.11-1.77.Conclusion: Overall, the findings indicate that alcohol use is a risk factor for suicide. Therefore, it seems that prevention and control of alcohol use can be effective in promoting mental health.

Suicide, Alcohol Intoxication, and Age Among Whites and American Indians/Alaskan Natives

BACKGROUND

Among American Indians/Alaskan Natives (AI/ANs), suicides are disproportionately high among those younger than 40 years of age. This paper examines suicide and alcohol intoxication (postmortem BAC ≥ 0.08 g/dl) by age among Whites and AI/ANs to better understand the reasons for the high rate of suicide among AI/ANs for those younger than 40.

METHODS

Data come from the restricted 2003 to 2016 National Violent Death Reporting System (NVDRS), with postmortem information on 79,150 White and AI/AN suicide decedents of both genders who had a BAC test in 32 states of the United States.

RESULTS

Among Whites, 39.3% of decedents legally intoxicated are younger than 40 years of age, while among AI/ANs the proportion is 72.9% (p < 0.001). Multivariable logistic regression with data divided by age shows that in the 18 to 39 age group, AI/ANs are about 2 times more likely than Whites to have a postmortem BAC ≥ 0.08. Veteran status compared to nonveteran, and history of alcohol problems prior to suicide were also associated with BAC ≥ 0.08. Suicide methods other than by firearm and a report of the presence of 2 or more suicide precipitating circumstances were protective against BAC ≥ 0.08. Results for the age group 40 years of age and older mirror those for the younger group with 1 exception: Race/ethnicity was not associated with BAC level.

CONCLUSIONS

The proportion of suicide decedents with a BAC ≥ 0.08 is higher among AI/ANs than Whites, especially among those 18 to 39 years of age. However, acute alcohol intoxication does not fully explain differences in suicide age structure between AI/ANs and Whites.

A drink before suicide: analysis of the Queensland Suicide Register in Australia

AIMS

Previous studies analysing blood alcohol concentration (BAC) at the time of suicide have primarily focused on sociodemographic factors. Limited research has focused on psychosocial factors and co-ingestion of other substances to understand the mechanisms of how alcohol contributes to death by suicide. The aim was to examine time trends, psychosocial factors related to acute alcohol use and co-ingestion of alcohol and other substances before suicide.

METHODS

The Queensland Suicide Register in 2004-2015 was utilised and analysed in 2019. The cut-off point for positive BAC was set at ⩾0.05 g/dl. Substances were categorised as medicines, illegal drugs and other. Medicines were coded by the Anatomical Therapeutic Chemical (ATC) classification system. Joinpoint regression, univariate odds ratios, age and sex-adjusted odds ratios and Forward Stepwise logistic regression were performed.

RESULTS

BAC information was available for 6744 suicides, 92% of all cases in 2004-2015. The final model showed that independent factors distinguishing BAC+ from BAC- were: age group 25-44 years, Australian Indigenous background, being separated or divorced, hanging, diagnosis of substance use, lifetime suicidal ideation, relationship and interpersonal conflict, not having psychotic and other psychiatric disorder, and no nervous system drugs or any other substances in blood at the time of suicide.

CONCLUSIONS

Our findings suggest that people who die by suicide while under the influence of alcohol are more likely to be under acute stress (e.g. separation) and not have earlier psychiatric conditions, except substance use. This highlights the importance of more strict alcohol policies, but also the need to improve substance use treatment.

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.

Suicidal Ideation, Suicidal Attempts, and Self-Harm in the UK Armed Forces

INTRODUCTION

In the UK military, suicide is infrequent and studies of self-harm behavior in this population are rare.

OBJECTIVES

To compare lifetime self-harm rates estimated on three occasions between 2004 and 2016 and to explore the associates of lifetime self-harm.

METHOD

Three phases of a UK AF cohort study (n = 10,272, 9,990, and 8,581, respectively) provided data. Telephone interviews assessed associates of self-harm among cohort members who reported subjective mental health problems in the past 3 years (n = 1,448). Validated measures of mental health and related stigmatization, social support, and help-seeking were obtained.

RESULTS

Lifetime self-harm increased significantly (p < .001) from 1.8% among serving personnel and 3.8% among veterans in 2004/06 to 1.9% and 4.5% in 2007/09 and to 4.2% and 6.6% in 2014/16 in the two groups, respectively. Veterans were consistently significantly more likely to report lifetime self-harm than serving personnel. Significant determinants of lifetime self-harm included current mental disorder symptoms, stigmatization, poor social support, suicidal ideation, and seeking help from formal medical sources.

CONCLUSION

Self-harm has increased over time in the UK serving and veteran community. Suicide prevention should focus on ameliorating mental disorder by encouraging engagement with health care, reducing negative views of mental illness, and fostering social support.

A preliminary examination of the association between drinking as a typical coping strategy and level of acute alcohol consumption prior to a suicide attempt

Drinking to cope is associated with suicide ideation and attempts. Event-based research shows drinking, particularly when alcohol is consumed in large quantities, increases the intensity of suicidal thoughts and immediate risk for attempt. Such findings suggest those who typically drink to cope may be especially likely to drink heavily in the hours preceding a suicide attempt. In the first examination of the association between regular use of alcohol as a coping strategy and acute alcohol consumption prior to a suicide attempt, participants included 130 patients hospitalized for a recent attempt. The number of drinks consumed in the acute period preceding the attempt, as well as past-year heavy drinking frequency, typical drinking motives, and depressive symptoms were assessed. The unique impacts of coping motives on odds of consuming any alcohol, and of using specific amounts of alcohol in the acute period, were determined through binary and multinomial logistic regressions. Results demonstrated that commonly drinking for coping motives increased the odds of heavy drinking - but not of using alcohol at low levels - during the acute period. Results held after adjusting for relevant covariates. Clinicians should assess drinking motives and prioritize prevention of drinking to cope to reduce risk of alcohol-related suicide attempts.

Differentiating adults who think about self-harm from those who engage in self-harm: the role of volitional alcohol factors

BACKGROUND

Self-harm, an act of self-poisoning or self-injury irrespective of motivation, is a major public health concern. Use of alcohol prior to or alongside acts of self-harm is common but little is known about the alcohol-related mechanisms of self-harm enaction. We utilised an ideation-to-action approach to clarify the extent to which volitional alcohol factors differentiated those who have thoughts of self-harm but do not act on them (self-harm ideation) and those who engage in self-harm (self-harm enaction).

METHODS

Cross-sectional analyses of the baseline phase of the Health Lifestyle and Wellbeing study: 1546 adults (1079 female; Mean age = 34 y; 92% White) resident in Scotland completed measures of demographics, lifetime self-harm, volitional alcohol factors and psychosocial factors. Multinomial logistic regression compared those with a history of self-harm thoughts ('ideation', n = 297), self-harm acts ('enaction', n = 346) and 'controls' (n = 897) to identify volitional alcohol factors associated with self-harm enaction.

RESULTS

Volitional alcohol factors differentiated those with a history of self-harm enaction from those with a history of self-harm ideation (as well as those with no history) in initial models adjusted for demographics and depressive symptoms: the self-harm enaction group reported stronger alcohol-related negative urgency (OR = 1.74, 95% CI 1.41-2.16, p < .001), more frequent heavy drinking (OR = 1.46, 95% CI 1.24-1.72, p < .001) and stronger expectancies that drinking alcohol leads to negative self-perceptions (OR = 1.33, 95% CI 1.03-1.72, p = 0.03) and markers of self-harm risk (OR = 1.64, 95% CI 1.18-2.30, p = 0.004). Alcohol-related negative urgency and heavy-drinking frequency continued to differentiate those in the self-harm enaction group from those in ideation group in multivariate models. Consistent with theoretical models positing phase-specific moderators of self-harm ideation and enaction, psychosocial factors (perceived stress, support, negative mood regulation expectancies) differentiated those with a history of self-harm ideation from those without but not those in the ideation and enaction groups.

CONCLUSIONS

Management of self-harm risk requires better understanding of alcohol-related mechanisms of self-harm enaction. Volitional alcohol factors may play a role in governing the translation of self-harm thoughts into self-harm acts.

Solitary drinking and the risk of depressive symptoms and suicidal ideation in college students: Findings from a nationwide survey in Korea

BACKGROUND

Despite the fact that solitary drinking is becoming more common in Korea, few studies have investigated the association between drinking alone and mental health. This study aimed to investigate the relationship between solitary drinking, depressive symptoms, and suicidal ideation in Korean college students.

METHOD

Primary data on a nationally representative sample of college students were used. Data were collected by Yonsei University and the Korean Center for Disease Control in 2017 to investigate alcohol-related behaviors and health consequences in students. The association between solitary drinking, depressive symptoms, and suicidal ideation were measured using multivariate logistic regression analysis.

RESULTS

A total of 3,935 students were analyzed, in which 11.5% had depressive symptoms and 2.8% suicidal ideation. Compared to non-solitary drinkers, solitary drinkers were more likely to have depressive symptoms [Odds Ratio (OR) 2.28, 95% Confidence Interval (95% CI) 1.72-3.02] and suicidal ideation (OR 2.24, 95% CI 1.32-3.81). Moreover, larger differences were found in individuals with higher alcohol use disorders identification test (AUDIT) scores and with more frequent underage drinking experience.

LIMITATIONS

As this study was cross-sectional in design, causal inferences cannot be made on the association between solitary drinking, depressive symptoms, and suicidal ideation.

CONCLUSION

Solitary drinking is associated with higher likelihoods of depressive symptoms and suicidal ideation in college students. The results suggest the importance of monitoring solitary drinkers as they may be more vulnerable to the negative mental health effects of alcohol.

A systematic review on the relationship between childhood exposure to external cause parental death, including suicide, on subsequent suicidal behaviour

BACKGROUND

Exposure to parental death in childhood has been associated with offspring suicide risk, although the strength of this association is unclear. The primary aim of this systematic review was to synthesise primary studies on the relationship between childhood exposure to external cause parental death, including suicide, and subsequent suicidal behaviour in adulthood. The secondary objective was to compare suicide-related outcomes of exposure to parental suicide with the outcomes of exposure to other external cause parental deaths.

METHODS

A systematic review was conducted using guidelines from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Ovid MEDLINE, Cochrane Library, Ovid PsycINFO, Web of Science, CINAHL and EMBASE were searched from January 2008 until November 2018. Two researchers independently screened the articles, performed data extraction and assessed quality of evidence using the Newcastle-Ottawa Scale.

RESULTS

Of the 618 studies identified, 26 were included for review. Only one study found no significant association between childhood exposure to suicide and increased suicide risk in adulthood. Four studies suggested the risk of suicidality in adulthood was greater for those exposed to parental suicide compared to other external cause deaths.

LIMITATIONS

The use of national registers in many studies did not allow for all variables of interest to be examined. Selective samples also limited the generalizability of findings.

CONCLUSIONS

A strong association between parental suicide and suicidal behaviour in adult offspring exists. Interventions for bereaved youth should consider the long-term effects of parental suicide and target individual and environmental-level risk factors for subsequent suicidality.