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Shen Y, Yuan S, Liu J, Sun B, Chen Z, Zheng L, Chen L, Chen H, Feng H, He H. The reliability, validity and screening effect of the happiness index scale among inpatients in a general hospital. BMC Psychiatry 2022; 22:601. [PMID: 36085028 PMCID: PMC9463772 DOI: 10.1186/s12888-022-04219-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 08/24/2022] [Indexed: 03/06/2023] Open
Abstract
BACKGROUND The Happiness Index Scale (HIS) is a newly developed scale by our group to screen for common psychological illnesses among general hospital inpatients. This study aimed to analyze the reliability, validity and screening effect of the HIS and to explore its clinical application. METHODS From April 1, 2021, to December 31, 2021, a total of 8405 continuous inpatients were enrolled from different departments of a large tertiary general hospital with 1385 inpatient beds in Guangzhou, Guangdong Province, China. Using a cross-sectional survey design, each participant was assessed with the Patient Health Questionnaire 9(PHQ-9), Generalized Anxiety Disorder 7 items(GAD-7), Athens Insomnia Scale (AIS), Columbia Suicide Severity Rating Scale (C-SSRS) and HIS within 24 h of admission. McDonald's ω coefficient, the Guttman split-half coefficient and the test-retest reliability coefficient were used to evaluate the reliability of the HIS and the construct validity and criterion validity of the validity tests. Scores on the PHQ-9, GAD-7, AIS, and C-SSRS were used as the gold standard tools to analyze the screening effect of the HIS. RESULTS The HIS exhibited very good reliability, with a McDonald's ω coefficient of 0.825, a Guttman split-half coefficient of 0.920 and a test-retest reliability coefficient of 0.745 (P < 0.05). Confirmatory factor analysis showed a satisfactory model fitting index with a χ2/df = 2.602, a root mean squared error of approximation (RMSEA) of 0.014, a standardized root mean square residual (SRMR) of 0.010, a comparative fit index (CFI) of 0.992, and a Tucker-Lewis index (TLI) of 0.983. The correlation coefficient between the total score of each dimension of the scale and the corresponding criterion was 0.854 ~ 0.949 (P < 0.001). The HIS showed a very good distinguishing effect. The average HIS score of inpatients who screened positive for psychological problems was significantly higher than that of inpatients who screened negative for psychological problems (t = 3790.619, P < 0.001). The effect size was very large (Cohens d = 2.695, 95% CI = 2.630 ~ 2.761). Approximately 90.2% of the positive and negative screening results of the HIS were matched with the gold standard tools, with a kappa value of 0.747 (P < 0.001). The screening effect test showed a sensitivity (true positive rate) of 92.9% and a specificity (true negative rate) of 89.5%. CONCLUSION The HIS exhibited satisfactory reliability and validity and a clinically meaningful screening effect with a much shorter version compared to the commonly used screening scales. Thus, it could potentially be useful as the first screening step to rule out psychological conditions for inpatients in general hospitals or to remind medical teams of further psychological concerns.
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Affiliation(s)
- Yizhong Shen
- grid.410737.60000 0000 8653 1072The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China ,The Third People’s Hospital of Zhuhai, Zhuhai, China
| | - Shuai Yuan
- grid.410737.60000 0000 8653 1072The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China
| | - Jingwen Liu
- grid.410737.60000 0000 8653 1072The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China
| | - Bin Sun
- grid.410737.60000 0000 8653 1072The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China
| | - Zilin Chen
- grid.410737.60000 0000 8653 1072The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China
| | - Lijiao Zheng
- The Third People’s Hospital of Zhuhai, Zhuhai, China
| | - Lihao Chen
- The Third People’s Hospital of Zhuhai, Zhuhai, China
| | - Hanwei Chen
- The Third People’s Hospital of Zhuhai, Zhuhai, China
| | - Huiqiang Feng
- grid.459864.20000 0004 6005 705XGuangzhou Panyu Central Hospital, Guangzhou, China
| | - Hongbo He
- The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China.
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Robins JE, Kalk NJ, Ross KR, Pritchard M, Curtis V, Morley KI. The association of acute alcohol use and dynamic suicide risk with variation in onward care after psychiatric crisis. Drug Alcohol Rev 2021; 40:499-508. [PMID: 33569872 PMCID: PMC8647926 DOI: 10.1111/dar.13231] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 11/10/2020] [Accepted: 11/18/2020] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Despite the association of alcohol use with recurrent suicidal acts, individuals attempting suicide after drinking alcohol face barriers accessing crisis care following emergency assessment, demonstrated by higher odds of inpatient admission for those whose suicide attempt did not feature alcohol. This disparity may be due to suicidality dissipating more rapidly after a suicide attempt involving alcohol. We investigated the effect of acute alcohol use and ongoing suicidality on onward care decisions after emergency assessment. METHODS We analysed electronic health records of 650 suicidal adults detained under Section 136 of the Mental Health Act (1983, amended 2007) for up to 36 h at a London psychiatric emergency care centre. We used logistic regression to estimate the association of acute alcohol use and ongoing suicidality (including their interaction) with admission to psychiatric hospital. RESULTS Fifteen percent of previously intoxicated detainees expressed suicidal intent at detention end, compared to 24% of detainees who had not used alcohol prior to detention. Compared to those who were not previously intoxicated and not suicidal at detention end, acute alcohol use was associated with reduced odds of admission amongst those no longer suicidal (AOR 0.4, 95% CI 0.2, 0.6). Where suicidality persisted, odds of admission rose; however, the magnitude of increase when in combination with prior alcohol use (AOR 3.6, 95% CI 1.9, 7.1) was under half that of when alcohol was not involved (AOR 8.2, 95% CI 3.5, 19.1). DISCUSSION AND CONCLUSIONS Acute alcohol use is associated with transient suicidality, but this only partially accounts for disparities in care following suicide attempts.
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Affiliation(s)
- John E. Robins
- National Addiction CentreKing's College London Institute of Psychiatry, Psychology and NeuroscienceLondonUK
- South London and Maudsley NHS Foundation TrustLondonUK
| | - Nicola J. Kalk
- National Addiction CentreKing's College London Institute of Psychiatry, Psychology and NeuroscienceLondonUK
- South London and Maudsley NHS Foundation TrustLondonUK
| | - Kezia R. Ross
- National Addiction CentreKing's College London Institute of Psychiatry, Psychology and NeuroscienceLondonUK
| | - Megan Pritchard
- South London and Maudsley NHS Foundation TrustLondonUK
- NIHR Maudsley Biomedical Research CentreLondonUK
- King's College London Institute of Psychiatry, Psychology and NeuroscienceLondonUK
| | - Vivienne Curtis
- South London and Maudsley NHS Foundation TrustLondonUK
- King's College London Institute of Psychiatry, Psychology and NeuroscienceLondonUK
- School of Psychiatry, Health Education EnglandLondonUK
| | - Katherine I. Morley
- National Addiction CentreKing's College London Institute of Psychiatry, Psychology and NeuroscienceLondonUK
- South London and Maudsley NHS Foundation TrustLondonUK
- Innovation, Health, and Science, RAND EuropeCambridgeUK
- Centre for Epidemiology and BiostatisticsMelbourne School of Global and Population Health, The University of MelbourneMelbourneAustralia
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Conner KR, Kearns JC, Esposito EC, Pizzarello E, Wiegand TJ, Britton PC, Michel K, Gysin-Maillart AC, Goldston DB. Pilot RCT of the Attempted Suicide Short Intervention Program (ASSIP) adapted for rapid delivery during hospitalization to adult suicide attempt patients with substance use problems. Gen Hosp Psychiatry 2021; 72:66-72. [PMID: 34304029 PMCID: PMC8448954 DOI: 10.1016/j.genhosppsych.2021.07.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 07/09/2021] [Accepted: 07/13/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The Attempted Suicide Short Intervention Program (ASSIP) was adapted for hospital delivery and to address substance use problems as well as evaluated for feasibility, acceptability, and therapist fidelity in a series of preparatory steps (n = 28) and in a pilot randomized controlled trial, RCT (n = 34). METHOD In the RCT, patients with suicide attempts and substance use problem(s) with sufficient lengths of stay to deliver three ASSIP therapy sessions in hospital were randomized to adapted ASSIP or treatment as usual control. A blinded assessor identified suicide reattempts over 6-month follow-up with the Columbia-Suicide Severity Rating Scale (C-SSRS) and a comprehensive multi-source method. Treatment process measures and the Scale for Suicidal Ideation (SSI) were also administered. RESULTS Median hospital stay was 13 days. ASSIP subjects reported high satisfaction with the treatment and high therapeutic alliance. Study therapists showed high fidelity to the modified ASSIP intervention. Repetition of suicide attempt was common in both study groups including a combined 9 (26%) subjects with reattempt based on C-SSRS and 13 (38%) subjects with reattempt based on multiple sources. CONCLUSIONS Adult suicide attempt patients with substance use problems who require lengthy hospitalizations are at exceptionally high risk and may require additional strategies to lower risk.
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Affiliation(s)
| | - Jaclyn C. Kearns
- Department of Psychology, University of Rochester, Rochester, NY, USA
| | - Erika C. Esposito
- Department of Psychology, University of Rochester, Rochester, NY, USA
| | | | | | - Peter C. Britton
- University of Rochester Medical Center, Rochester, NY, USA,Center of Excellence for Suicide Prevention, Finger Lakes VA Healthcare System, Canandaigua, NY, USA
| | - Konrad Michel
- University Hospital of Psychiatry, Bern, Switzerland
| | - Anja C. Gysin-Maillart
- Translational Research Centre, University Hospital of Psychiatry, University of Bern, Switzerland,Unit for Clinical Suicide Research, Department of Clinical Sciences, Psychiatry, Faculty of Medicine, Lund University, Sweden,University of Leipzig Department of Medical Psychology and Medical Sociology
| | - David B. Goldston
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
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Boenisch S, Bramesfeld A, Mergl R, Havers I, Althaus D, Lehfeld H, Niklewski G, Hegerl U. The Role Of Alcohol Use Disorder And Alcohol Consumption In Suicide Attempts-A Secondary Analysis Of 1921 Suicide Attempts. Eur Psychiatry 2020; 25:414-20. [DOI: 10.1016/j.eurpsy.2009.11.007] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2009] [Revised: 11/09/2009] [Accepted: 11/09/2009] [Indexed: 10/19/2022] Open
Abstract
AbstractBackgroundIt 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.MethodsData 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.ResultsIn 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.ConclusionsIndividuals 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.
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Conner KR, Wiegand TJ, Goldston DB. A hospital-based treatment of suicide attempt patients with problematic alcohol use: Rationale and treatment development. Gen Hosp Psychiatry 2020; 63:30-32. [PMID: 30765239 DOI: 10.1016/j.genhosppsych.2019.02.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 01/25/2019] [Accepted: 02/04/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Problematic alcohol use (PAU) is a potent risk factor for suicidal behavior yet individuals with PAU presenting to hospital with suicidal risk may receive less intensive hospital-based treatment than suicidal patients without PAU. Developing efficacious interventions for at-risk patients with PAU that may be delivered in hospital is critical, particularly for those hospitalized following a suicide attempt, a group at marked risk. METHOD The authors identified the Attempted Suicide Short Intervention Program (ASSIP) for adaption for hospitalized suicide attempt patients with PAU because of its flexibility, brevity, and evidence of efficacy to reduce risk for suicide reattempt. After consulting with the developers of ASSIP, clinical research experts in the treatment of suicidal risk and PAU, and treatment providers of hospitalized suicide attempt patients, the authors made modifications to ASSIP to tailor it to hospitalized suicide attempt patients with PAU. Results and conclusion Our modifications to ASSIP include highlighting links between PAU and the timing of the attempt; integrating such links into the narrative story of the attempt, the written case formulation, and the homework task; and identifying concrete strategies to address PAU-related risk in the prevention plan. These modifications are the focus of an ongoing treatment development study.
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Affiliation(s)
- Kenneth R Conner
- University of Rochester Medical Center, United States of America.
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6
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Calati R, Cohen LJ, Schuck A, Levy D, Bloch-Elkouby S, Barzilay S, Rosenfield PJ, Galynker I. The Modular Assessment of Risk for Imminent Suicide (MARIS): A validation study of a novel tool for suicide risk assessment. J Affect Disord 2020; 263:121-128. [PMID: 31818767 DOI: 10.1016/j.jad.2019.12.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 09/16/2019] [Accepted: 12/01/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Reliable diagnostic tools for the short-term suicide risk assessment are needed. The recently developed multi-informant Modular Assessment of Risk for Imminent Suicide (MARIS) includes four modules: two are patient-rated and two clinician-rated. The patient-rated modules assess a proposed pre-suicidal cognitive/emotional state (Module 1) as well as patients' attitudes towards suicide (Module 2). The clinician-rated modules assess traditional suicide risk factors (Module 3) and clinicians' emotional responses to the patient (Module 4). METHODS With the aim of extending our previous preliminary proof of concept findings, the MARIS was administered to 618 psychiatric patients (167 inpatients, 451 outpatients) and their clinicians (N = 115). Patients were assessed with a battery including the Columbia-Suicide Severity Rating Scale. Four outcomes were considered: lifetime and past month suicidal thoughts and behaviors (STB) (0-10 point scale) and suicidal behaviors (SB) (0-5 point scale). Reliability and concurrent, convergent/divergent and incremental validity were assessed. RESULTS Good internal consistency was found for modules 1 and 4 (Cronbach's α: 0.87 and 0.86, respectively) but not for the others. Module 1's total score positively correlated with lifetime STB/SB and past month STB (all p ≤ 0.003). Module 4's total score positively correlated with all four outcomes (all p < 0.001). Modules 1 and 4 showed additional capacity to detect patients' lifetime and past month STB/SB beyond other associated factors. LIMITATIONS Lack of prospective assessment. Inpatients were evaluated at discharge, whereas outpatients at intake. CONCLUSIONS These findings supported the utility of multiple data sources to identify patients at imminent suicide risk, and in particular clinicians' emotional responses.
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Affiliation(s)
- Raffaella Calati
- Department of Psychiatry, Mount Sinai Beth Israel, New York, NY, USA; Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Psychology, University of Milan-Bicocca, Milan, Italy; Department of Adult Psychiatry, Nîmes University Hospital, Nîmes, France.
| | - Lisa J Cohen
- Department of Psychiatry, Mount Sinai Beth Israel, New York, NY, USA; Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Allison Schuck
- Department of Psychiatry, Mount Sinai Beth Israel, New York, NY, USA
| | - Dorin Levy
- Department of Psychiatry, Mount Sinai Beth Israel, New York, NY, USA; Department of Psychiatry, Mount Sinai St. Luke's and Mount Sinai West, USA
| | - Sarah Bloch-Elkouby
- Department of Psychiatry, Mount Sinai Beth Israel, New York, NY, USA; Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Shira Barzilay
- Department of Psychiatry, Mount Sinai Beth Israel, New York, NY, USA; Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Paul J Rosenfield
- Department of Psychiatry, Mount Sinai St. Luke's and Mount Sinai West, USA
| | - Igor Galynker
- Department of Psychiatry, Mount Sinai Beth Israel, New York, NY, USA; Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Salles J, Tiret B, Gallini A, Gandia P, Arbus C, Mathur A, Bougon E. Suicide Attempts: How Does the Acute Use of Alcohol Affect Suicide Intent? Suicide Life Threat Behav 2020; 50:315-328. [PMID: 31532854 DOI: 10.1111/sltb.12586] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 06/17/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Very few studies have specifically addressed the role of the acute use of alcohol (AUA) in suicide attempts. OBJECTIVE Our study compared the suicide intent scores of self-poisoning patients with and without AUA in order to examine the role of alcohol in attempted suicides. METHODS We recruited 516 patients admitted to the emergency department for self-poisoning. We screened blood alcohol concentrations (BACs) to determine whether these were positive or negative in the two groups. We collected data about covariates such as psychiatric disorders and sociodemographic and suicide characteristics. We then compared suicide intent between the groups, adjusted according to the covariates. RESULTS The patients with AUA had lower scores for suicide intent, but this factor only reduced the self-reporting score, with the scores for objective circumstances and risk similar between the groups. There was a correlation between BACs and self-reported suicide intentionality, but this was not significant. CONCLUSION Acute use of alcohol patients presented with lower suicide intent, as particularly explained by the self-report scores, but there were no differences between the groups in terms of risk and/or the objective circumstances. The role of alcohol in the self-reporting of suicide attempts must be addressed in future studies.
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Affiliation(s)
- Juliette Salles
- Université de Toulouse III, Toulouse, France.,Service de Psychiatrie et Psychologie, Psychiatrie Toulouse, CHU Toulouse, Toulouse, France.,INSERM U1043, Centre de Physiopathologie de Toulouse Purpan, Université Paul Sabatier, Toulouse, France
| | - Bernard Tiret
- Service de Psychiatrie et Psychologie, Psychiatrie Toulouse, CHU Toulouse, Toulouse, France
| | - Adeline Gallini
- Université de Toulouse III, Toulouse, France.,Département d'Épidémiologie et de Santé Publique, Institut Fédératif de Biologie, CHU Toulouse, Toulouse, France
| | - Peggy Gandia
- Université de Toulouse III, Toulouse, France.,Service de Pharmacocinétique et Toxicologie, Institut Fédératif de Biologie, CHU Toulouse, Toulouse, France
| | - Christophe Arbus
- Université de Toulouse III, Toulouse, France.,Service de Psychiatrie et Psychologie, Psychiatrie Toulouse, CHU Toulouse, Toulouse, France
| | - Anjali Mathur
- Service de Psychiatrie et Psychologie, Psychiatrie Toulouse, CHU Toulouse, Toulouse, France
| | - Emmanuelle Bougon
- Service de Psychiatrie et Psychologie, Psychiatrie Toulouse, CHU Toulouse, Toulouse, France
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8
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Salles J, Calonge J, Franchitto N, Bougon E, Schmitt L. Factors associated with hospitalization after self-poisoning in France: special focus on the impact of alcohol use disorder. BMC Psychiatry 2018; 18:287. [PMID: 30189841 PMCID: PMC6127999 DOI: 10.1186/s12888-018-1854-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 08/16/2018] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Previous studies have identified factors associated with admission to hospital after suicide spectrum behaviors. In this study, we aim to identify specific factors associated with psychiatric hospitalization after self-poisoning. Given earlier findings suggesting that alcohol use disorder is not associated with hospital admission, we also aim to consider its impact, as well as blood alcohol concentrations, on hospitalization decisions after a suicide attempt. METHODS We studied the association between demographic features, suicide intent, psychiatric characteristics and admission to hospital in self-poisoning patients in an emergency department in France. RESULTS Suicide intent, a past history of suicide attempts, bipolar disorder and depression were associated with psychiatric hospital admissions. Despite alcohol use disorder being known to be associated with a suicide risk, it was not linked with psychiatric hospitalization. A positive blood alcohol concentration in the emergency department likewise had no association with admission to a psychiatric ward for inpatient care. CONCLUSIONS Our findings were similar to those reported for other suicide spectrum behaviors. Alcohol use disorder was not associated with admission for inpatient psychiatric care, whereas depression clearly was. The cause of this discrepancy must be determined in future research.
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Affiliation(s)
- Juliette Salles
- Université de Toulouse III, F-31000 Toulouse, France
- CHU Toulouse, Service de Psychiatrie eSt Psychologie, Psychiatrie, F-31000 Toulouse, France
- CHU Toulouse, Service d’addictologie clinique, urgences réanimation médecine, F-31000 Toulouse, France
| | - Julie Calonge
- Université de Toulouse III, F-31000 Toulouse, France
| | - Nicolas Franchitto
- Université de Toulouse III, F-31000 Toulouse, France
- CHU Toulouse, Service d’addictologie clinique, urgences réanimation médecine, F-31000 Toulouse, France
| | - Emmanuelle Bougon
- Université de Toulouse III, F-31000 Toulouse, France
- CHU Toulouse, Service de Psychiatrie eSt Psychologie, Psychiatrie, F-31000 Toulouse, France
| | - Laurent Schmitt
- Université de Toulouse III, F-31000 Toulouse, France
- CHU Toulouse, Service de Psychiatrie eSt Psychologie, Psychiatrie, F-31000 Toulouse, France
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McCaffery R, Lee A, Jauhar P, Scott J. A survey of opinions on the management of individuals who express suicidal ideation while intoxicated with alcohol. PSYCHIATRIC BULLETIN 2018. [DOI: 10.1192/pb.26.9.332] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Aims and MethodIt was noted that approaches to the assessment and management of individuals intoxicated with alcohol who express suicidal ideation varied widely. This study explored what guidance is currently available and sought the opinions of 218 junior and senior psychiatrists.ResultsThe Royal College of Psychiatrists has no specific guidelines on this issue, but the Medical Defence Union and Scottish Central Legal Office gave opinion regarding a psychiatrist's duty of care and clinical responsibilities. This information did not reflect the opinions of the psychiatrists canvassed. There was no consensus among the 65% of clinicians who responded to the survey.Clinical ImplicationsThere is a need for greater clarity and guidance on the management of individuals who are intoxicated and express acute suicidal ideation. Sharing of good practice guidelines and greater integration of local and national policies is needed. It is certainly a topic worthy of inclusion in all induction days for junior psychiatrists.
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10
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Kim E, Jeong KY, Lee JS, Choi HS. Predictive Value of Psychological Scales for Hospitalization of Elderly Suicide Attempters. Ann Geriatr Med Res 2017. [DOI: 10.4235/agmr.2017.21.4.197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Eundo Kim
- Department of Emergency Medicine, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Ki Young Jeong
- Department of Emergency Medicine, Kyung Hee University Medical Center, Seoul, Korea
- Department of Emergency Medicine, Kyung Hee University School of Medicine, Seoul, Korea
| | - Jong Seok Lee
- Department of Emergency Medicine, Kyung Hee University Medical Center, Seoul, Korea
- Department of Emergency Medicine, Kyung Hee University School of Medicine, Seoul, Korea
| | - Han Sung Choi
- Department of Emergency Medicine, Kyung Hee University Medical Center, Seoul, Korea
- Department of Emergency Medicine, Kyung Hee University School of Medicine, Seoul, Korea
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11
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Characteristics of completed suicide in different blood alcohol concentrations in Korea. Forensic Sci Int 2017; 281:37-43. [DOI: 10.1016/j.forsciint.2017.10.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 07/08/2017] [Accepted: 10/11/2017] [Indexed: 11/19/2022]
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Larkin C, Griffin E, Corcoran P, McAuliffe C, Perry IJ, Arensman E. Alcohol Involvement in Suicide and Self-Harm. CRISIS 2017; 38:413-422. [DOI: 10.1027/0227-5910/a000488] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Abstract. Background: Alcohol misuse and alcohol consumption are significant risk factors for suicidal behavior. Aims: This study sought to identify factors associated with alcohol consumption in cases of suicide and nonfatal self-harm presentations. Method: Suicide cases in Cork, Ireland, from September 2008 to June 2012 were identified through the Suicide Support and Information System. Emergency department presentations of self-harm in the years 2007–2013 were obtained from the National Self-Harm Registry Ireland. Results: Alcohol consumption was detected in the toxicology of 44% out of 307 suicide cases. Only younger age was significantly associated with having consumed alcohol among suicides. Alcohol consumption was noted in the case notes in 21% out of 8,145 self-harm presentations. Logistic regression analyses indicated that variables associated with having consumed alcohol in a self-harm presentation included male gender, older age, overdose as a method, not being admitted to a psychiatric ward, and presenting out-of-hours. Limitations: Data was limited to routinely collected variables by the two different monitoring systems. Conclusion: Alcohol consumption commonly precedes suicidal behavior, and several factors differentiated alcohol-related suicidal acts. Self-harm cases, in particular, differ in profile when alcohol is consumed and may require a tailored clinical approach to minimize risk of further nonfatal or fatal self-harm.
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Affiliation(s)
| | - Eve Griffin
- National Suicide Research Foundation, Cork, Ireland
| | - Paul Corcoran
- National Suicide Research Foundation, Cork, Ireland
- School of Public Health, University College Cork, Ireland
| | | | - Ivan J. Perry
- School of Public Health, University College Cork, Ireland
| | - Ella Arensman
- National Suicide Research Foundation, Cork, Ireland
- School of Public Health, University College Cork, Ireland
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Clinical Prediction of Suicide and Undetermined Death: A Pseudo-Prospective Clinical and Medico-Legal Study of Substance Abusers. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2017; 14:ijerph14030310. [PMID: 28304357 PMCID: PMC5369146 DOI: 10.3390/ijerph14030310] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 03/01/2017] [Accepted: 03/14/2017] [Indexed: 12/02/2022]
Abstract
This study examines aspects of prediction of suicide and death of undetermined intent. We investigated all consecutive, autopsied patients between 1993 and 1997 who had been in contact with the Addiction Centre in Malmö from 1968 onwards. The staff was asked, shortly after autopsy but before they knew of the manner of death, if they thought the patient had committed suicide. The case records were blindly evaluated, and toxicological autopsy findings for alcohol in blood samples investigated. The specificity of prediction was 83% and significantly more often correct than the sensitivity, which was only 45% for suicide and for suicide/death of undetermined intent (93% versus 39%). Suicidal communication was more often considered non-serious before death of undetermined intent than before suicide. The former could be predicted by ideation but not by suicide attempt reported in case records, unlike suicide, which was predicted by both. The undetermined group also showed higher levels of alcohol in the blood at autopsy. We concluded that more serious clinical investigation of suicidal feelings, which may be hidden and not taken seriously, and treatment of alcohol use disorders with active follow-up appear urgent in the efforts to prevent suicide.
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Hawes M, Yaseen Z, Briggs J, Galynker I. The Modular Assessment of Risk for Imminent Suicide (MARIS): A proof of concept for a multi-informant tool for evaluation of short-term suicide risk. Compr Psychiatry 2017; 72:88-96. [PMID: 27771563 DOI: 10.1016/j.comppsych.2016.10.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 09/15/2016] [Accepted: 10/04/2016] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND To date, no diagnostic tool has demonstrated clinical value for the assessment of short-term suicide risk among high-risk individuals. To this end we have developed the Modular Assessment of Risk for Imminent Suicide (MARIS), a modular patient and clinician informed risk evaluation instrument. Here we assess its predictive validity for suicidal behavior (SB) in psychiatric patients following discharge from an inpatient unit. METHODS The MARIS and a psychological test battery were administered to 136 adult psychiatric patients hospitalized for high risk of suicide. Eighty-six participants had complete data at discharge and 59 (69.8%) were reached for follow-up. Logistic regressions were used to assess the predictive validity of the MARIS for SB over the 4-8weeks following hospital discharge and its incremental predictive validity over standard risk factors. RESULTS Patients who exhibited SB in the period between initial assessment and follow-up had significantly higher MARIS scores. ROC analysis indicated good sensitivity and specificity of MARIS in identifying risk (OR=19). Further, MARIS total score significantly improved predictive validity by the standard risk factors when added to a model comprising global depression severity, hopelessness, and lifetime number of suicide attempts, and was the only factor that approached independent significance. CONCLUSION The MARIS appears to be a practical and effective tool for detecting short-term suicide risk following hospital discharge, supporting the validity of modular multi-informant approach to suicide risk evaluation. Replication of these findings and further investigation of the applications of such an approach are warranted.
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Affiliation(s)
- Mariah Hawes
- Mount Sinai Beth Israel, Department of Psychiatry, 317 E 17th St, New York, NY 10003, USA
| | - Zimri Yaseen
- Mount Sinai Beth Israel, Department of Psychiatry, 317 E 17th St, New York, NY 10003, USA
| | - Jessica Briggs
- Mount Sinai Beth Israel, Department of Psychiatry, 317 E 17th St, New York, NY 10003, USA
| | - Igor Galynker
- Mount Sinai Beth Israel, Department of Psychiatry, 317 E 17th St, New York, NY 10003, USA.
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15
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Rossow I. Suicide, Violence and Child Abuse: A Review of the Impact of Alcohol Consumption on Social Problems. ACTA ACUST UNITED AC 2016. [DOI: 10.1177/009145090002700303] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The literature on empirical studies of alcohol consumption and its impact on three categories of social problems—suicide, violence, and child abuse—is reviewed. A large literature on alcohol consumption and its impact on suicide and violence comprises empirical studies applying various methods and designs. The rather consistent findings across these studies show that more drinking is associated with a higher risk of experiencing suicidal behavior or violence. Moreover, frequent intoxication seems to be a key factor in alcohol's role in suicide and violence. The empirical studies on alcohol consumption and child abuse are less extensive, the findings are less consistent in demonstrating an association, and many studies have been met with methodological criticism. This is clearly an area where more research, applying various and strong designs, is needed. More knowledge on how and why alcohol consumption is associated with these social problems should also be among future research challenges.
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16
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Bagge CL, Conner KR, Reed L, Dawkins M, Murray K. Alcohol use to facilitate a suicide attempt: an event-based examination. J Stud Alcohol Drugs 2016; 76:474-81. [PMID: 25978835 DOI: 10.15288/jsad.2015.76.474] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The current study is based on the hypothesis that alcohol-involved suicide attempts are characterized by lower premeditation and intent, but only when the use of alcohol is not motivated by the desire to facilitate the attempt. Test of this idea was conducted by comparing proximal suicide premeditation and intent of suicide attempts among three groups: individuals who (a) drank to facilitate the attempt (e.g., to "numb fears" about attempting), (b) drank for nonfacilitative motives, and (c) did not use alcohol before the attempt. METHOD Participants included 324 (62% female) recent suicide attempters presenting to a Level 1 trauma hospital. The Timeline Followback Interview for Suicide Attempts and a novel Suicide Facilitative Drinking Motives Scale were used to assess facilitative motives for drinking and characteristics of the attempt. RESULTS One third of participants drank before the attempt, and most (73%) who used alcohol did not do so to facilitate the attempt. As hypothesized, attempts carried out by this group had shorter proximal suicide premeditation and lower suicide intent compared with the other study groups; in contrast, individuals who drank to facilitate the attempt were similar to non-alcohol users on these indices. CONCLUSIONS Alcohol-involved suicide attempts are heterogeneous. Motives for drinking are a key source of heterogeneity insofar as fundamental characteristics of attempts (proximal premeditation, intent) differ as a function of drinking motivation. Clinical implications include that individuals making suicide attempts with facilitative motives for drinking cannot be assumed to be at lowered risk upon a drop in blood alcohol level.
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Affiliation(s)
- Courtney L Bagge
- Department of Psychiatry and Human Behavior, University of Mississippi Medical Center, Jackson, Mississippi
| | - Kenneth R Conner
- Department of Psychiatry, University of Rochester Medical Center, Rochester, New York.,VISN 2 Center of Excellence for Suicide Prevention, Canandaigua, New York
| | - Louren Reed
- Department of Psychiatry and Human Behavior, University of Mississippi Medical Center, Jackson, Mississippi
| | - Milton Dawkins
- Department of Psychiatry and Human Behavior, University of Mississippi Medical Center, Jackson, Mississippi
| | - Kevin Murray
- Department of Psychiatry and Human Behavior, University of Mississippi Medical Center, Jackson, Mississippi
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Ghanbari B, Malakouti SK, Nojomi M, De Leo D, Saeed K. Alcohol Abuse and Suicide Attempt in Iran: A Case-Crossover Study. Glob J Health Sci 2015; 8:58-67. [PMID: 26925903 PMCID: PMC4965666 DOI: 10.5539/gjhs.v8n7p58] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 10/12/2015] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Behrooz Ghanbari
- Mental Health Research Center (MHRC), Tehran Institute of Psychiatry, School of behavioral sciences and mental health, Iran University of Medical Sciences (IUMS), Tehran, Iran.
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Oh SH, Kim HJ, Kim SH, Kim YM, Park KN. Which deliberate self-poisoning patients are most likely to make high-lethality suicide attempts? Int J Ment Health Syst 2015; 9:35. [PMID: 26347801 PMCID: PMC4561421 DOI: 10.1186/s13033-015-0028-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Accepted: 08/31/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The risk/rescue rating scale (RRRS) assesses the lethality of a suicide attempt, which is defined as the probability of inflicting irreversible damage. We assessed the lethality of suicide attempts using the RRRS and identified the socio-demographic profiles of patients who achieved high lethality in deliberate self-poisoning (DSP). METHODS A retrospective study was conducted to evaluate DSP patients who visited the emergency department of a tertiary teaching hospital between 2000 and 2011. The data included socio-demographic information, clinical variables, risk factors (e.g., the method used, whether consciousness was impaired, toxicity, reversibility and whether treatment was required) and rescue factors (e.g., location, who initiated the rescue, the probability of discovery, the accessibility of rescue, and delay until discovery). The high-risk group consisted of patients with 11-15 risk points, whereas patients in the low-rescue group had 5-11 risk points. We examined the characteristics of high-lethality suicide attempts (high-risk/low-rescue group). RESULTS A total of 1114 patients were enrolled in this study. Pearson's correlation analysis showed that the total risk score for patients with DSP was negatively associated with the total rescue score (r = -0.201, p < 0.001). Of the total number of DSP patients, 42 were included in the high-risk/low-rescue group. The multivariate logistic regression analyses showed significant associations between high-lethality suicide attempts and male gender (OR 2.70, 95 % CI 1.41-5.18, p = 0.003), older age (OR 1.02, 95 % CI 1.01-1.04, p = 0.015), and unemployment (OR 2.98, 95 % CI 1.41-6.33, p = 0.004). CONCLUSION This retrospective study demonstrates that male gender, advanced age, and unemployed status were associated with high-lethality suicide attempts in DSP patients.
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Affiliation(s)
- Sang Hoon Oh
- Department of Emergency Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701 Republic of Korea
| | - Han Joon Kim
- Department of Emergency Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701 Republic of Korea
| | - Soo Hyun Kim
- Department of Emergency Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701 Republic of Korea
| | - Young Min Kim
- Department of Emergency Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701 Republic of Korea
| | - Kyu Nam Park
- Department of Emergency Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701 Republic of Korea
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Pennel L, Quesada JL, Begue L, Dematteis M. Is suicide under the influence of alcohol a deliberate self-harm syndrome? An autopsy study of lethality. J Affect Disord 2015; 177:80-5. [PMID: 25745839 DOI: 10.1016/j.jad.2015.02.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Revised: 01/30/2015] [Accepted: 02/06/2015] [Indexed: 11/15/2022]
Abstract
BACKGROUND Alcohol is a risk factor for suicide and is often involved in violent actions. The aim of the study was to assess the involvement of alcohol in suicides and its relationship with the lethality of suicide methods. METHODS In a retrospective study on autopsy reports, we compared suicide and non-suicide victims, suicides with positive and negative blood alcohol concentration (BAC), and studied the lethality of suicide methods using a multivariate analysis. RESULTS Suicide victims (n=88) were not different to non-suicide victims (n=270) for positive BAC and narcotics, but were more often positive for prescription medications (59.1 vs. 35.6%, p=0.003) and medications in blood (72.7 vs. 54.8%, p=0.004). Whereas non-suicidal victims died mainly of traumas (60%, p<0.001), two populations of suicides emerged with regard to BAC, self-poisoning predominating with positive BAC (38.9%, p=0.039) and asphyxiation with negative BAC (41.4%, p=0.025). Positive BAC appeared as the unique and strong independent predictive factor, increasing the risk of self-poisoning suicide by 4.36 [1.29-14.76], and decreasing the risk of suicidal asphyxiation by 84% (OR=0.16 [0.03-0.83]). Positive blood narcotics tended to behave in the similar way to alcohol. LIMITATIONS Recruitment bias (victims declared by the Forensic authorities) and incomplete autopsy reports are the two main limitations. CONCLUSIONS Characteristics of suicide victims with positive BAC are suggestive of Deliberate Self-Harm Syndrome (low lethality methods, substance misuse). These being at high risk of repeated suicide attempts, previous self-harm involving alcohol may represent a warning sign and access to medication should be limited to prevent recidivism.
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Affiliation(s)
- Lucie Pennel
- Université Grenoble Alpes, Faculty of Medicine, Grenoble F-38042, France; INSERM U836, Team 10, Grenoble F-38042, France; University Hospital, Department of Addiction Medicine, Grenoble F-38043, France
| | - Jean-Louis Quesada
- University Hospital, Clinical Research and Innovation Direction, Grenoble F-38043, France
| | - Laurent Begue
- Inter-university Laboratory of Psychology, EA4145, University of Grenoble 2, France
| | - Maurice Dematteis
- Université Grenoble Alpes, Faculty of Medicine, Grenoble F-38042, France; University Hospital, Department of Addiction Medicine, Grenoble F-38043, France; INSERM U1042, Grenoble F-38042, France.
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20
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Dissociation et passage à l’acte violent : une revue de littérature. EVOLUTION PSYCHIATRIQUE 2015. [DOI: 10.1016/j.evopsy.2014.09.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Moustgaard H, Joutsenniemi K, Myrskylä M, Martikainen P. Antidepressant sales and the risk for alcohol-related and non-alcohol-related suicide in Finland--an individual-level population study. PLoS One 2014; 9:e98405. [PMID: 24892560 PMCID: PMC4043885 DOI: 10.1371/journal.pone.0098405] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Accepted: 05/01/2014] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES A marked decline in suicide rates has co-occurred with increased antidepressant sales in several countries but the causal connection between the trends remains debated. Most previous studies have focused on overall suicide rates and neglected differential effects in population subgroups. Our objective was to investigate whether increasing sales of non-tricyclic antidepressants have reduced alcohol- and non-alcohol-related suicide risk in different population subgroups. METHODS We followed a nationally representative sample of 950,158 Finnish adults in 1995-2007 for alcohol-related (n = 2,859) and non-alcohol-related (n = 8,632) suicides. We assessed suicide risk by gender and social group according to regional sales of non-tricyclic antidepressants, measured by sold doses per capita, prevalence of antidepressant users, and proportion of antidepressant users with doses reflecting minimally adequate treatment. Fixed-effects Poisson regression models controlled for regional differences and time trends that may influence suicide risk irrespective of antidepressant sales. RESULTS The number of sold antidepressant doses per capita and the prevalence of antidepressant users were unrelated to male suicide risk. However, one percentage point increase in the proportion of antidepressant users receiving minimally adequate treatment reduced non-alcohol-related male suicide risk by one percent (relative risk 0.987, 95% confidence interval 0.976-0.998). This beneficial effect only emerged among men with high education, high income, and employment, among men without a partner, and men not owning their home. Alcohol-related suicides and female suicides were unrelated to all measures of antidepressant sales. CONCLUSION We found little evidence that increase in overall sales or in the prevalence of non-tricyclic antidepressant users would have caused the fall in suicide rates in Finland in 1995-2007. However, the rise in the proportion of antidepressant users receiving minimally adequate treatment, possibly due to enhanced treatment compliance, may have prevented non-alcohol-related suicides among men.
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Affiliation(s)
- Heta Moustgaard
- Population Research Unit, Department of Social Research, University of Helsinki, Finland
| | - Kaisla Joutsenniemi
- Department of Mental Health and Substance Abuse Services, National Institute for Health and Welfare, Helsinki, Finland
| | - Mikko Myrskylä
- Department of Social Policy, London School of Economics and Political Science, London, United Kingdom
| | - Pekka Martikainen
- Population Research Unit, Department of Social Research, University of Helsinki, Finland
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22
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Riedi G, Mathur A, Séguin M, Bousquet B, Czapla P, Charpentier S, Genestal M, Cailhol L, Birmes P. Alcohol and Repeated Deliberate Self-Harm. CRISIS 2012; 33:358-63. [DOI: 10.1027/0227-5910/a000148] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background: Repeated episode(s) of deliberate self-harm (RDSH) is a major risk factor for suicide. Aims: To identify specific risk factors for RDSH among patients admitted following an episode of deliberate self-harm (DSH) through acute intoxication. Methods: A prospective 6-month study was conducted with 184 patients (71% female) admitted to the emergency room (ER) as a result of self-poisoning (SP). Results: Rate of RDSH stood at 18% after 6 months. The sociodemographic variables associated with repeated deliberate self-harm were to have no principal activity, consultation with a medical professional during the 6 months preceding the self-poisoning, and referral to psychiatric services upon release from the ER. The clinical variable associated with RDSH was alcohol addiction (OR = 2.7; IC 95% = 1.2–6.1, p < .05) as assessed at the time of the initial ER admission. Conclusions: When patients are initially admitted to the ER as a result of self-poisoning, it is important to evaluate specific factors, particularly alcohol use, that could subsequently lead to repeated deliberate self-harm. The goal is to improve the targeting and referral of patients toward structures that can best respond to their needs.
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Affiliation(s)
- G. Riedi
- Toulouse University, UPS, Laboratoire du Stress Traumatique, France
| | - A. Mathur
- Toulouse University, UPS, Laboratoire du Stress Traumatique, France
| | - M. Séguin
- McGill Group for Suicide Studies, Douglas Hospital Research Center, Montréal, Canada
| | - B. Bousquet
- Toulouse University, UPS, Laboratoire du Stress Traumatique, France
| | - P. Czapla
- Toulouse University, UPS, Laboratoire du Stress Traumatique, France
| | - S. Charpentier
- Adult ER, Purpan Hospital, Toulouse University Hospital, France
| | - M. Genestal
- Anesthesiology and Intensive Care, Purpan Hospital, Toulouse University Hospital, France
| | - L. Cailhol
- National Institute of Health and Medical Research (INSERM), Clinical Investigation Center 9302, Purpan Hospital, Toulouse University Hospital, France
| | - P. Birmes
- Toulouse University, UPS, Laboratoire du Stress Traumatique, France
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Ronquillo L, Minassian A, Vilke GM, Wilson MP. Literature-based recommendations for suicide assessment in the emergency department: a review. J Emerg Med 2012; 43:836-42. [PMID: 23040403 DOI: 10.1016/j.jemermed.2012.08.015] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2012] [Accepted: 08/15/2012] [Indexed: 11/25/2022]
Abstract
BACKGROUND Suicidal ideation and attempted suicide are important presenting complaints in the Emergency Department (ED). The Joint Commission established a National Patient Safety Goal that requires screening for suicidal ideation to identify patients at risk for suicide. OBJECTIVES Given the emphasis on screening for suicidal ideation in the general hospital and ED, it is important for Emergency Physicians to be able to understand and perform suicide risk assessment. METHODS A review of literature was conducted using PubMed to determine important elements of suicide assessment in adults, ages 18 years and over, in the ED. Four typical ED cases are presented and the assessment of suicide risk in each case is discussed. RESULTS The goal of an ED evaluation is to appropriately determine which patients are at lowest suicide risk, and which patients are at higher or indeterminate risk such that psychiatry consultation is warranted while the patient is in the ED. Emergency clinicians should estimate this risk by taking into account baseline risk factors, such as previous suicide attempts, as well as acute risk factors, such as the presence of a suicide plan. CONCLUSION Although a brief screening of suicide risk in the ED does not have the sensitivity to accurately determine which patients are at highest risk of suicide after leaving the ED, patients at lowest risk may be identified. In these low-risk patients, psychiatric holds and real-time psychiatric consultation while in the ED may not be needed, facilitating more expeditious dispositions from the ED.
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Affiliation(s)
- Linda Ronquillo
- Alliant International University, California School of Professional Psychology, San Diego, California 92122, USA
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24
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Craig DGN, Bates CM, Davidson JS, Martin KG, Hayes PC, Simpson KJ. Overdose pattern and outcome in paracetamol-induced acute severe hepatotoxicity. Br J Clin Pharmacol 2011; 71:273-82. [PMID: 21219409 PMCID: PMC3040549 DOI: 10.1111/j.1365-2125.2010.03819.x] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2010] [Accepted: 08/31/2010] [Indexed: 12/19/2022] Open
Abstract
AIMS Paracetamol (acetaminophen) hepatotoxicity is the commonest cause of acute liver failure (ALF) in the UK. Conflicting data regarding the outcomes of paracetamol-induced ALF resulting from different overdose patterns are reported. METHODS Using prospectively defined criteria, we have analysed the impact of overdose pattern upon outcome in a cohort of 938 acute severe liver injury patients admitted to the Scottish Liver Transplantation Unit. RESULTS Between 1992 and 2008, 663 patients were admitted with paracetamol-induced acute severe liver injury. Of these patients, 500 (75.4%) had taken an intentional paracetamol overdose, whilst 110 (16.6%) had taken an unintentional overdose. No clear overdose pattern could be determined in 53 (8.0%). Unintentional overdose patients were significantly older, more likely to abuse alcohol, and more commonly overdosed on compound narcotic/paracetamol analgesics compared with intentional overdose patients. Unintentional overdoses had significantly lower admission paracetamol and alanine aminotransferase concentrations compared with intentional overdoses. However, unintentional overdoses had greater organ dysfunction at admission, and subsequently higher mortality (unintentional 42/110 (38.2%), intentional 128/500 (25.6%), P < 0.001). The King's College poor prognostic criteria had reduced sensitivity in unintentional overdoses (77.8%, 95% confidence intervals (CI) 62.9, 88.8) compared with intentional overdoses (89.9%, 95% CI 83.4, 94.5). Unintentional overdose was independently predictive of death or liver transplantation on multivariate analysis (odds ratio 1.91 (95% CI 1.07, 3.43), P = 0.032). CONCLUSIONS Unintentional paracetamol overdose is associated with increased mortality compared with intentional paracetamol overdose, despite lower admission paracetamol concentrations. Alternative prognostic criteria may be required for unintentional paracetamol overdoses.
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Affiliation(s)
- Darren G N Craig
- Scottish Liver Transplantation Unit, Royal Infirmary of Edinburgh, Little France, Edinburgh EH16 4SA, UK
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25
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Miller M, Borges G, Orozco R, Mukamal K, Rimm EB, Benjet C, Medina-Mora ME. Exposure to alcohol, drugs and tobacco and the risk of subsequent suicidality: findings from the Mexican Adolescent Mental Health Survey. Drug Alcohol Depend 2011; 113:110-7. [PMID: 20801585 DOI: 10.1016/j.drugalcdep.2010.07.016] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2009] [Revised: 03/16/2010] [Accepted: 07/03/2010] [Indexed: 10/19/2022]
Abstract
AIMS To examine whether the association between prevalence measures of suicidality and substance abuse/dependence among adolescents (1) is attenuated when temporal priority of exposure and outcome are taken into account, (2) extends to substance use (i.e. without disorder), (3) applies to tobacco use and dependence independent of illicit drugs and alcohol use/disorder, and (4) is confounded by comorbid mental illness. DESIGN Discrete-time survival models were applied to retrospectively reported age of onset of first suicidal ideation, plan and attempt and age of onset of first substance use and disorder. PARTICIPANTS 3005 adolescents aged 12-17 residing in the Mexico City Metropolitan Area in 2005. MEASUREMENTS The World Mental Health computer-assisted adolescent version of the Composite International Diagnostic Interview was used to assess suicidal outcomes and psychiatric disorders including substance dependence/abuse. FINDINGS Use of and dependence on tobacco is as strong a predictor of subsequent suicidality as is use of and dependence with abuse of alcohol and drugs. The association between substance use and subsequent suicidality is not fully accounted for by comorbid mental illness. CONCLUSION Efforts to reduce the use as well as the abuse of alcohol, drugs and tobacco may help reduce the risk of subsequent suicidal behaviors among adolescents in Mexico.
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Affiliation(s)
- M Miller
- Department of Health Policy and Management, Harvard School of Public Health, 677 Huntington Avenue, Room 305, Kresge Building, Boston, MA 02115, United States.
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Epidemiology of acute poisonings during 2003–2007 in toxicology unit, department of occupational medicine and toxicology, Nofer Institute of Occupational Medicine, Łódź, Poland. Int J Occup Med Environ Health 2011; 24:199-207. [DOI: 10.2478/s13382-011-0016-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2011] [Accepted: 03/01/2011] [Indexed: 11/21/2022] Open
Abstract
Abstract
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27
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Reyes JC, Robles RR, Colón HM, Negrón JL, Matos TD, Calderón JM. Polydrug use and attempted suicide among Hispanic adolescents in Puerto Rico. Arch Suicide Res 2011; 15:151-9. [PMID: 21541861 DOI: 10.1080/13811118.2011.565274] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
This study was aimed at examining the relationship between suicidal attempts, polydrug use, and depression in adolescents. A sample of 691 adolescents and their parents were interviewed. Subjects who met the criteria for depression and those who used alcohol were significantly more likely to be suicidal attempters (OR = 6.8, p < 0.001; OR = 7.5, p < 0.001). Polydrug users were significantly more likely to attempt suicide (OR = 8.8, p = 0.032). Adolescents with mothers who met the criteria for depression were more likely to report suicide attempts (OR = 2.4, p = 0.069). Health professionals need to screen for polydrug use and depression to prevent future suicidal behaviors.
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Affiliation(s)
- Juan C Reyes
- Institute of Research, Education and Services on Addiction, Universidad Central del Caribe, School of Medicine, Bayamon, Puerto Rico.
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28
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Castro-Rueda VA, Martínez-Villalba AMR, Camacho PA, Rueda-Jaimes GE. Factores de riesgo y protectores para intento suicida en adultos colombianos con suicidabilidad. ACTA ACUST UNITED AC 2010. [DOI: 10.1016/s0034-7450(14)60210-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Crawford MJ, Csipke E, Brown A, Reid S, Nilsen K, Redhead J, Touquet R. The effect of referral for brief intervention for alcohol misuse on repetition of deliberate self-harm: an exploratory randomized controlled trial. Psychol Med 2010; 40:1821-1828. [PMID: 20047702 DOI: 10.1017/s0033291709991899] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Referral for brief intervention among people who misuse alcohol is reported to be effective but its impact among those who present to services following deliberate self-harm (DSH) has not been examined. METHOD Consecutive patients who presented to an Emergency Department (ED) following an episode of DSH were screened for alcohol misuse. Those found to be misusing alcohol were randomly assigned to brief intervention plus a health information leaflet or to a health information leaflet alone. The primary outcome was whether the patient reattended an ED following a further episode of DSH during the subsequent 6 months. Secondary outcomes were alcohol consumption, mental health and satisfaction with care measured 3 and 6 months after randomization. RESULTS One hundred and three people took part in the study. Follow-up data on our primary outcome were obtained for all subjects and on 63% for secondary outcomes. Half those referred for brief intervention received it. Repetition of DSH was strongly associated with baseline alcohol consumption, but not influenced by treatment allocation. There was a non-significant trend towards the number of units of alcohol consumed per drinking day being lower among those randomized to brief intervention. CONCLUSIONS Referral for brief intervention for alcohol misuse following an episode of DSH may not influence the likelihood of repetition of self-harm. Longer-term interventions may be needed to help people who deliberately harm themselves and have evidence of concurrent alcohol misuse.
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Affiliation(s)
- M J Crawford
- Department of Psychological Medicine, Imperial College London, UK.
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Pompili M, Serafini G, Innamorati M, Dominici G, Ferracuti S, Kotzalidis GD, Serra G, Girardi P, Janiri L, Tatarelli R, Sher L, Lester D. Suicidal behavior and alcohol abuse. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2010; 7:1392-431. [PMID: 20617037 PMCID: PMC2872355 DOI: 10.3390/ijerph7041392] [Citation(s) in RCA: 227] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/19/2010] [Revised: 03/15/2010] [Accepted: 03/19/2010] [Indexed: 12/22/2022]
Abstract
Suicide is an escalating public health problem, and alcohol use has consistently been implicated in the precipitation of suicidal behavior. Alcohol abuse may lead to suicidality through disinhibition, impulsiveness and impaired judgment, but it may also be used as a means to ease the distress associated with committing an act of suicide. We reviewed evidence of the relationship between alcohol use and suicide through a search of MedLine and PsychInfo electronic databases. Multiple genetically-related intermediate phenotypes might influence the relationship between alcohol and suicide. Psychiatric disorders, including psychosis, mood disorders and anxiety disorders, as well as susceptibility to stress, might increase the risk of suicidal behavior, but may also have reciprocal influences with alcohol drinking patterns. Increased suicide risk may be heralded by social withdrawal, breakdown of social bonds, and social marginalization, which are common outcomes of untreated alcohol abuse and dependence. People with alcohol dependence or depression should be screened for other psychiatric symptoms and for suicidality. Programs for suicide prevention must take into account drinking habits and should reinforce healthy behavioral patterns.
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Affiliation(s)
- Maurizio Pompili
- Department of Neuroscience, Mental Health and Sensory Functions, Suicide Prevention Center, Sant’Andrea Hospital, Sapienza University of Rome, Rome 00189, Italy; E-Mails:
(G.S.);
(M.I.);
(G.D.);
(S.F.);
(G.D.K.);
(G.S.);
(P.G.);
(R.T.)
- McLean Hospital, Harvard Medical School, Belmont, MA 02478, USA
- Author to whom correspondence should be addressed; E-Mail:
or
; Tel. +39-06 33775675; Fax +39-0633775342
| | - Gianluca Serafini
- Department of Neuroscience, Mental Health and Sensory Functions, Suicide Prevention Center, Sant’Andrea Hospital, Sapienza University of Rome, Rome 00189, Italy; E-Mails:
(G.S.);
(M.I.);
(G.D.);
(S.F.);
(G.D.K.);
(G.S.);
(P.G.);
(R.T.)
| | - Marco Innamorati
- Department of Neuroscience, Mental Health and Sensory Functions, Suicide Prevention Center, Sant’Andrea Hospital, Sapienza University of Rome, Rome 00189, Italy; E-Mails:
(G.S.);
(M.I.);
(G.D.);
(S.F.);
(G.D.K.);
(G.S.);
(P.G.);
(R.T.)
| | - Giovanni Dominici
- Department of Neuroscience, Mental Health and Sensory Functions, Suicide Prevention Center, Sant’Andrea Hospital, Sapienza University of Rome, Rome 00189, Italy; E-Mails:
(G.S.);
(M.I.);
(G.D.);
(S.F.);
(G.D.K.);
(G.S.);
(P.G.);
(R.T.)
| | - Stefano Ferracuti
- Department of Neuroscience, Mental Health and Sensory Functions, Suicide Prevention Center, Sant’Andrea Hospital, Sapienza University of Rome, Rome 00189, Italy; E-Mails:
(G.S.);
(M.I.);
(G.D.);
(S.F.);
(G.D.K.);
(G.S.);
(P.G.);
(R.T.)
| | - Giorgio D. Kotzalidis
- Department of Neuroscience, Mental Health and Sensory Functions, Suicide Prevention Center, Sant’Andrea Hospital, Sapienza University of Rome, Rome 00189, Italy; E-Mails:
(G.S.);
(M.I.);
(G.D.);
(S.F.);
(G.D.K.);
(G.S.);
(P.G.);
(R.T.)
| | - Giulia Serra
- Department of Neuroscience, Mental Health and Sensory Functions, Suicide Prevention Center, Sant’Andrea Hospital, Sapienza University of Rome, Rome 00189, Italy; E-Mails:
(G.S.);
(M.I.);
(G.D.);
(S.F.);
(G.D.K.);
(G.S.);
(P.G.);
(R.T.)
| | - Paolo Girardi
- Department of Neuroscience, Mental Health and Sensory Functions, Suicide Prevention Center, Sant’Andrea Hospital, Sapienza University of Rome, Rome 00189, Italy; E-Mails:
(G.S.);
(M.I.);
(G.D.);
(S.F.);
(G.D.K.);
(G.S.);
(P.G.);
(R.T.)
| | - Luigi Janiri
- Department of Psychiatry, Catholic University Medical School, Largo F. Vito 1, Rome 00168, Italy; E-Mail:
| | - Roberto Tatarelli
- Department of Neuroscience, Mental Health and Sensory Functions, Suicide Prevention Center, Sant’Andrea Hospital, Sapienza University of Rome, Rome 00189, Italy; E-Mails:
(G.S.);
(M.I.);
(G.D.);
(S.F.);
(G.D.K.);
(G.S.);
(P.G.);
(R.T.)
| | - Leo Sher
- Department of Psychiatry, Columbia University, New York, NY 10032, USA; E-Mail:
| | - David Lester
- The Richard Stockton College of New Jersey, Pomona, NJ 08240-0195, USA; E-Mail:
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Webb L. Counting girls out: A review of suicide among young substance misusers and gender difference implications in the evaluation of risk. DRUGS-EDUCATION PREVENTION AND POLICY 2009. [DOI: 10.1080/09687630701801404] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Sher L, Oquendo MA, Richardson-Vejlgaard R, Makhija NM, Posner K, Mann JJ, Stanley BH. Effect of acute alcohol use on the lethality of suicide attempts in patients with mood disorders. J Psychiatr Res 2009; 43:901-5. [PMID: 19246050 PMCID: PMC3767468 DOI: 10.1016/j.jpsychires.2009.01.005] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2008] [Accepted: 01/16/2009] [Indexed: 10/21/2022]
Abstract
Acute alcohol use is an important risk factor for attempted and completed suicide. We evaluated the effect of acute alcohol intake on the lethality of suicide attempts to test the hypothesis that acute alcohol intoxication is associated with more lethal suicide attempts. This retrospective study included 317 suicide attempters enrolled in mood disorders protocols. Demographic and clinical parameters were assessed. The use of alcohol at the time of the most lethal suicide attempt was determined. On the basis of their responses participants were classified into three groups: participants who reported "Enough alcohol intake to impair judgment, reality testing and diminish responsibility" or "Intentional intake of alcohol in order to facilitate implementation of attempt" were included in the group "Alcohol" (A); participants who reported "Some alcohol intake prior to but not related to attempt, reportedly not enough to impair judgment, reality testing" were included in the group "Some Alcohol" (SA); and participants who reported "No alcohol intake immediately prior to attempt" were included in the group "No Alcohol" (NA). Lethality of the most lethal suicide attempts was higher in the A group compared to the SA and NA groups. Prevalence of patients with alcohol use disorders was higher in the A group compared to the SA and NA groups. SA participants reported more reasons for living and lower suicide intent scores at the time of their most lethal suicide attempt compared to the A and NA groups. Acute alcohol use increases the lethality of suicide attempts in individuals with mood disorders.
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Affiliation(s)
- Leo Sher
- Department of Psychiatry, Division of Molecular Imaging and Neuropathology, New York State Psychiatric Institute, Columbia University, 1051 Riverside Drive, Suite 2917, Box 42, New York, NY 10032, USA.
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Suicidality and trait aggression related to childhood victimization in patients with alcoholism. Psychiatry Res 2009; 165:103-10. [PMID: 19038461 DOI: 10.1016/j.psychres.2007.11.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2006] [Revised: 06/12/2007] [Accepted: 11/11/2007] [Indexed: 11/23/2022]
Abstract
The relationship between physical abuse in childhood and suicide attempts in adulthood has long been known. However, the phenomenon has not been examined in patients who are undergoing treatment for alcoholism. In this study we seek an answer to the questions of whether exposure to physical abuse in childhood predisposes to violence, which in turn increases the likelihood of suicidal behavior in adulthood. The sample studied comprised 172 patients with alcohol dependence and with data for childhood physical abuse, trait aggression and lifetime suicide attempts. The measuring instruments used for the investigation were the European Addiction Severity Index, the Buss and Perry Aggression Questionnaire and the Janus Questionnaire. Generalized Linear Model analysis revealed a significant gender-dependent association between physical abuse by the parents suffered in childhood and later suicide attempts. In females, childhood victimization by parents increased the likelihood of suicide attempts by approximately 15 times; in males, the increase was about twofold. Association of suicide attempts with the overall level of trait aggression also significantly interacted with gender. In females, the increase in the level of total scores of the trait aggression from 0 to 50 points (approximately the mean level in the study population) elevated the likelihood of the suicide attempts by almost ninefold, whereas the analogous increase in males was about threefold. The results draw attention to the importance of preventing suicide in clinical populations of alcohol-dependent patients.
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Berman ME, Bradley TP, Fanning JR, McCloskey MS. Self-focused attention reduces self-injurious behavior in alcohol-intoxicated men. Subst Use Misuse 2009; 44:1280-97. [PMID: 19938918 DOI: 10.1080/10826080902961328] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Both chronic alcohol use and acute intoxication are risk factors for self-aggression (i.e., intentional self-injury) across the spectrum of lethality. Studies designed to identify a cause-and-effect relation between alcohol intoxication and self-aggression, or the factors that facilitate or mitigate this effect, are rare due to the inherent difficulty of studying self-injurious behavior experimentally. In this study, we experimentally demonstrate that alcohol intoxication leads to heightened self-injurious behavior, and that enhanced self-focused attention (self-awareness) attenuates this effect. Specifically, 40 men consumed either alcohol (mean Blood Alcohol Concentration [BAC] = .10) or a veridical control drink, and then completed a laboratory task designed to assess self-injurious behavior. Self-focused attention was experimentally enhanced in half the participants in each drink condition. Results support the notion that prevention and intervention programs designed to reduce intentional self-injurious behaviors should include components that address alcohol misuse and self-awareness.
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Affiliation(s)
- Mitchell E Berman
- Department of Psychology, University of Southern Mississippi, Hattiesburg, Mississippi 39406-5025, USA.
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Lejoyeux M, Huet F, Claudon M, Fichelle A, Casalino E, Lequen V. Characteristics of suicide attempts preceded by alcohol consumption. Arch Suicide Res 2008; 12:30-8. [PMID: 18240032 DOI: 10.1080/13811110701800699] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Acute alcohol ingestion and alcohol dependence are known to increase the risk of impulsive suicide attempt even in non-depressed patients. The relation between alcohol and suicide risk needs, however, to be clarified. We assessed for this purpose prevalence of recent alcohol intake among suicide attempters and compared suicide attempts preceded ("Alcohol + ") or not by alcohol intake. We included 160 patients examined in the emergency service of a French general hospital after a suicide attempt. Psychiatric disorders were identified according to the DSM-IV criteria. Patients were rated for depression and alcohol use disorder (MAST). Prevalence of alcohol consumption was 40%. Patients from the "Alcohol + " group were significantly older (40 versus 34.8 years, p = 0.03). Alcohol abuse was more frequent among suicide attempters with prior alcohol ingestion (49% versus 12%,). Alcohol dependence was also more frequent in the "Alcohol + " group (43% versus 9%). Patients from the "Alcohol + " group drank more alcohol each day (6.1 versus 1.3 drinks) and more often during the week (3.6 days per week versus 1.4). They had a higher number of alcohol intoxications each week (0.9 versus 0.3). They drank more often alone (41% versus 12%, p < 0.005) and in the morning (21% versus 3%). They had higher scores on the Michigan Alcohol Screening test (14.8 versus 2.9). Prevalence of drug dependence was higher in the "Alcohol + " group (21% versus 3%, respectively). Suicide attempts must be asked about their recent alcohol intake. This alcohol intake is often the symptom of an alcohol abuse or dependence disorder.
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Affiliation(s)
- Michel Lejoyeux
- Department of Psychiatry, Bichat-Claude Bernard Hospital, Paris, France.
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Rossow I, Ystgaard M, Hawton K, Madge N, van Heeringen K, de Wilde EJ, DeLeo D, Fekete S, Morey C. Cross-national comparisons of the association between alcohol consumption and deliberate self-harm in adolescents. Suicide Life Threat Behav 2007; 37:605-15. [PMID: 18275367 DOI: 10.1521/suli.2007.37.6.605] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
How differences in drinking patterns may affect the impact of alcohol consumption on deliberate self-harm among adolescents is explored in this international comparative study. Schools in Australia, Belgium, England, Hungary, Ireland, the Netherlands, and Norway (N = 30,532) were surveyed. In all countries the risk of deliberate self-harm was significantly elevated among adolescents who reported some or numerous episodes of intoxication, controlling for confounding factors. The results support the assumption that intoxication is significantly related to the association between alcohol consumption and deliberate self-harm in adolescents.
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Affiliation(s)
- Ingeborg Rossow
- Suicide Research and Prevention Unit, University of Oslo, Norway.
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37
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Li YM. Deliberate Self-harm and Relationship to Alcohol Use at an Emergency Department In Eastern Taiwan. Kaohsiung J Med Sci 2007; 23:247-53. [PMID: 17525007 DOI: 10.1016/s1607-551x(09)70405-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Suicide incidence has increased dramatically in recent years in Taiwan. In 2004, 3,468 lives were lost due to suicide and the total mortality was 15.3/100,000. It is well known that alcohol drinking raises the risk of deliberate self-harm (DSH), especially among psychologically distressed subjects. This study investigated the characteristics of DSH patients and their association with acute alcohol drinking. Since 2004, an injury surveillance system has been set up in a medical center, collecting the minimal information recommended by the World Health Organization. Attending nurses collected information and assessed each injured patient as to whether he/she smelled of alcohol. Medical records of DSH injuries were reviewed for confirmation of any prior DSH and any known mental disorder was checked. Of 11,837 injuries, 123 (1.0%) were DSH. Those who were first-time DSH patients (n = 115) were studied. About half of the patients were female and 83.5% were aged between 20 and 54 years. More than half of the DSH incidents occurred at home and 80.1% cases were stabbing or cutting injuries. Injuries were defined as alcohol-related based on the report of "alcohol odor'' or "intoxicated'' by the nurse or a positive blood alcohol test. In total, 55 (47.8%) DSH injuries were found to be alcohol-related. The proportion of alcohol-related injuries was highest (60.0%) in the age range 45-64 years. Of those patients who tested positive for alcohol (n = 21), the mean blood alcohol concentration was 211.2 mg/dL (standard deviation, 79.1). Most subjects were discharged from the emergency department (75.7%). Only 20 DSH patients (17.1%) went on to receive a psychiatric consultation. DSH is not uncommon in eastern Taiwan. Half of our cases were associated with alcohol use. Males had the same risk of injuring themselves and were more likely than females to adopt "severe" methods to injure themselves. Further studies into the causes of DSH or parasuicide attempts are needed. Psychiatric consultation is essential in caring for DSH patients and in preventing suicide. ADSH injury also offers an opportunity to recognize alcohol problems.
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Affiliation(s)
- Yin-Ming Li
- Department of Family Medicine, Buddhist Tzu Chi General Hospital, Tzu Chi University, Hualien, Taiwan.
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38
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Determinants of psychiatric hospitalization after attempted suicide. Gen Hosp Psychiatry 2006; 28:424-30. [PMID: 16950379 DOI: 10.1016/j.genhosppsych.2006.03.009] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2005] [Revised: 03/19/2006] [Accepted: 03/20/2006] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study investigated the characteristics of suicide attempters referred to psychiatric hospitals and the factors affecting such referral. METHOD All 1198 consecutive suicide attempters treated in general hospital emergency rooms in Helsinki during a 12-month period were identified. Data on all health care contacts 1 year before the index attempt and on referrals to psychiatric hospitals after the attempt were gathered. RESULTS We found that a quarter of patients were referred to psychiatric hospitals as inpatients after index suicide attempts. Factors predicting referral to psychiatric hospitals, compared to nonreferral, were older age, psychotic disorder, mood disorder, lack of alcohol consumption preceding the attempt, somatic illness, suicide attempt on a weekday, previous psychiatric treatment, psychiatric consultation and the hospital treating the suicide attempt. CONCLUSION Although the clinical characteristics of patients attempting suicide are a major determinant of whether they are subsequently referred to psychiatric hospitals, the treatment practices of emergency room hospitals also influence treatment decisions.
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Abstract
AIMS Despite recent small reductions in overall suicide rates, rates among those aged 25-44 have remained high. The aim of this paper was to examine the evidence for a link between alcohol misuse/consumption and suicidal behaviour, explore the reasons for this association, and consider the implications for reducing rates of suicidal behaviour. METHODS A medline search was performed to find relevant research evidence. RESULTS There is evidence to suggest alcohol misuse predisposes to suicidal behaviour through its depressogenic effects and promotion of adverse life events, and both behaviours may share a common genetic predisposition. Acute alcohol use can also precipitate suicidal behaviours through induction of negative affect and impairment of problem-solving skills, as well as aggravation of impulsive personality traits, possibly through effects on serotonergic neurotransmission. CONCLUSIONS Effective interventions for problem drinking may help reduce suicide rates. At a public health level, reducing overall alcohol consumption may be beneficial, and the measures shown to be most effective in this regard are those that aim to restrict availability of alcohol.
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Affiliation(s)
- John Brady
- General Adult Psychiatry, Holywell Hospital, 60 Steeple Road, Antrim BT41 2RJ, Northern Ireland.
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Valtonen H, Suominen K, Partonen T, Ostamo A, Lönnqvist J. Time patterns of attempted suicide. J Affect Disord 2006; 90:201-7. [PMID: 16412521 DOI: 10.1016/j.jad.2005.12.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2005] [Revised: 12/05/2005] [Accepted: 12/05/2005] [Indexed: 11/26/2022]
Abstract
BACKGROUND The association of mental disorders with time patterns of attempted suicide is poorly understood. METHODS The study material consisted of all consecutive suicide attempts admitted to health care in Helsinki during a one-year period from 15 January 1997 to 14 January 1998. Clinical diagnosis was made according to ICD-10. RESULTS Overall, the rate of suicide attempts varied markedly during the study period, peaking in autumn and being lowest during winter. Substance use disorders best explained suicide attempts occurring at weekends. There was considerable temporal variation among patients with mood disorders, compared to only slight variation among patients with schizophrenia spectrum disorders. Study subjects tended to contact health services in the late evening and around midnight. Those contacting health services outside normal hours received psychiatric consultation less frequently than others and were referred to aftercare less often. LIMITATIONS Structured Clinical Interviews for DSM-IV Axis I and II Disorders were not used. CONCLUSIONS There were marked time patterns of attempted suicide, especially among patients with mood disorders and substance use disorders. This contrasted with the limited fluctuation among patients with schizophrenia spectrum disorders. Contacts with the health care system occurred most often in the late evening and around midnight. The findings question the adequacy of staff numbers for psychiatric consultations and of time to plan aftercare.
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Affiliation(s)
- Hanna Valtonen
- Department of Mental Health and Alcohol Research, National Public Health Institute, Mannerheimintie 166, FI-00300 Helsinki, Finland
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O'Connell H, Lawlor BA. Recent alcohol intake and suicidality — a neuropsychological perspective. Ir J Med Sci 2005; 174:51-4. [PMID: 16445162 DOI: 10.1007/bf03168983] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Alcohol use disorders and suicidal behaviours are among the most prevalent and damaging of all psychiatric phenomena in Ireland and worldwide. Furthermore, alcohol use both chronic and acute has long been identified as a potent riskfactor for suicidal behaviour. AIMS In this paper, the authors review the observational and experimental evidence for the acute neuropsychological effects of alcohol intake on suicidal ideation and behaviour. METHODS A selective review of the literature was conducted, using the PubMed database. Search terms employed included 'alcohol', 'suicide', 'binge' and 'acute alcohol intake'. RESULTS Cognitive mechanisms implicated include alcohol-induced deficits in attention-allocation, prospective cognition, autobiographical memory and disinhibition. Emotional mechanisms include alcohol-induced dysphoria, depression and aggression. CONCLUSIONS This paper serves to highlight the importance of identifying and tackling acute alcohol intake and binge drinking as a risk factor for suicidal behaviour.
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Affiliation(s)
- H O'Connell
- Mercer's Institute for Research on Ageing, St. James's Hospital, Dublin 8.
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Nishimura ST, Goebert DA, Ramisetty-Mikler S, Caetano R. Adolescent alcohol use and suicide indicators among adolescents in Hawaii. CULTURAL DIVERSITY & ETHNIC MINORITY PSYCHOLOGY 2005; 11:309-20. [PMID: 16478351 DOI: 10.1037/1099-9809.11.4.309] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
Research on suicide has focused on gender, age, ethnicity, and psychiatric profiles. However, few studies have examined alcohol use and its relationship to suicide among Native Hawaiians and other Asian American/Pacific Islanders. This study analyzes data from the 1997 and 1999 Hawaii Youth Risk Behavior Survey to examine whether alcohol problems increase the risk for suicide indicators (as evidenced by responses to questions asking whether an individual has considered, planned, attempted, or required treatment for a suicide attempt). Drinking pattern was the best predictor for all suicide indicators. School and community-based programs can help to increase an adolescent's knowledge about the consequences of alcohol use and prevention of suicide.
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Affiliation(s)
- Stephanie T Nishimura
- Department of Psychiatry, John A. Burns School of Medicine, University of Hawaii at Manoa, Manoa, HI, USA.
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Hawton K, Simkin S, Fagg J. Deliberate self-harm in alcohol and drug misusers: patient characteristics and patterns of clinical care. Drug Alcohol Rev 2005; 16:123-9. [PMID: 16203418 DOI: 10.1080/09595239700186411] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The aims of this study were to describe the characteristics of alcohol and drug misusers presenting to a general hospital following suicide attempts and to investigate the patterns of clinical care they received before and after the attempts. The Oxford Monitoring System for Attempted Suicide and patient case-notes were used to obtain information on alcohol and drug misusers assessed by the general hospital psychiatric services after deliberate self-harm in 1992. Of 724 patients, 200 (28%) were substance misusers (36% of males, 23% of females). Both alcoholics and drug misusers were more likely than other attempters to be male, have histories of personality disorder and criminal offences and to make repeat attempts, and the drug misusers were more likely to be living alone and unemployed. These are characteristics associated with particularly high risk of suicide. A large proportion of the substance misusers had received specific treatment for their misuse before their attempts and the majority were offered this afterwards. Over a quarter did not accept the care they were offered. The general hospital management of attempted suicide patients must include systematic assessment for evidence of alcohol and drug misuse and maintain close links with substance misuse services. Patients identified as having problems in the use of alcohol without having developed dependence and/or physical symptoms are a group that warrants specific attention. Audits should be conducted in general hospitals to ensure that sufficient attention is being paid to the detection and management of suicide attempters with substance misuse.
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Affiliation(s)
- K Hawton
- University of Oxford, Department of Psychiatry, Warneford Hospital, UK
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Wines JD, Saitz R, Horton NJ, Lloyd-Travaglini C, Samet JH. Suicidal behavior, drug use and depressive symptoms after detoxification: a 2-year prospective study. Drug Alcohol Depend 2004; 76 Suppl:S21-9. [PMID: 15555813 DOI: 10.1016/j.drugalcdep.2004.08.004] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2004] [Accepted: 08/04/2004] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Individuals with substance-related disorders are at increased risk for suicidal behavior. Identifying those at higher risk for suicide among this population is difficult and informed mainly on the basis of cross-sectional data. METHODS We examined factors associated with drug-related suicidal behavior using multivariable regression analyses in a 2-year prospective study of 470 inpatients enrolled from an unlocked, detoxification unit. Suicidal behavior included suicidal ideation (SI) and suicide attempt (SA). RESULTS Lifetime prevalence for SI was 28.5%, and for SA, 21.9%. During the 2-year follow-up, 19.9% of the sample endorsed suicidal ideation and 6.9% reported a suicide attempt. Correlates of lifetime suicidal behavior included younger age, female, Hispanic, greater depressive symptoms, past sexual abuse, and problem sedative or alcohol use. Factors associated with suicidal behavior at follow-up included past suicidal behavior, more depressive symptoms, and more frequent benzodiazepine and alcohol use. Cocaine and heroin use did not reach statistical significance. CONCLUSIONS Suicidal behavior is common among individuals with substance-related disorders. Differences in "suicide potential" may exist between drug categories with CNS depressants increasing the risk. These findings highlight the importance of addressing the recurrent 'suicide risk' of patients with substance-related disorders and regular monitoring for changes in depressive symptoms and drug use. Based on the prevalence and severity of this problem, the role of universal suicide screening of individuals with substance-related disorders merits greater attention.
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Affiliation(s)
- James D Wines
- Alcohol and Drug Abuse Research Center (ADARC), McLean Hospital-Harvard Medical School, Boston, MA 02478, USA.
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Cherpitel CJ, Borges GLG, Wilcox HC. Acute alcohol use and suicidal behavior: a review of the literature. Alcohol Clin Exp Res 2004; 28:18S-28S. [PMID: 15166633 DOI: 10.1097/01.alc.0000127411.61634.14] [Citation(s) in RCA: 190] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Both acute and chronic use of alcohol are associated with suicidal behavior. However, the differing relationship of each component of alcohol use and possible causal mechanisms remain unclear. METHODS This article reviews and summarizes associations between acute alcohol consumption (with and without intoxication) and suicidal behavior (both completed suicide and suicide attempts) among adults 19 years and older, as presented in literature published between 1991 and 2001. Possible mechanisms and methodologic challenges for evaluating the association are also discussed. An application of a research design (the case-crossover study) that has the potential for addressing the effects of acute alcohol use over and above usual or chronic use is presented. RESULTS The majority of articles reviewed were restricted to descriptive studies that documented the prevalence of suicide completers or attempters who tested positive for alcohol use. A wide range of alcohol-positive cases were found for both completed suicide (10-69%) and suicide attempts (10-73%). Common methodologic limitations included the lack of control groups (for evaluating risk conferred by alcohol use), selection and ascertainment bias, and small sample sizes. The results of the case-crossover pilot study indicated substantially higher risk of suicide during or shortly after use of alcohol compared with alcohol-free periods. CONCLUSIONS Although there is a substantial literature of published studies on acute alcohol use and suicidal behavior, the majority of studies focus on completed suicide and report prevalence estimates. Findings from such studies are subject to several possible sources of bias and have not advanced our knowledge of mechanisms in the association between acute alcohol use and suicidal behavior. The case-crossover design may help to overcome some limitations of these studies and facilitate evaluation of associations and possible causal mechanisms by which acute alcohol use is linked to suicidal behavior.
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McCloskey MS, Berman ME. Alcohol intoxication and self-aggressive behavior. JOURNAL OF ABNORMAL PSYCHOLOGY 2003; 112:306-11. [PMID: 12784841 DOI: 10.1037/0021-843x.112.2.306] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Nonexperimental field studies have demonstrated an association between alcohol intoxication and self-aggressive behaviors across the spectrum of lethality. Although these results are suggestive, it is not yet known whether alcohol intoxication is causally related to self-aggression. The authors therefore experimentally examined the effects of alcohol intoxication (mean blood alcohol concentration of .10) on a behavioral measure of self-aggression in men (N = 40). After consuming either an alcohol or a placebo drink, participants were provided the opportunity to self-administer shock during a task disguised as a reaction-time game, with self-aggression defined by the intensity of shock chosen. Half of the participants observed a self-aggressive model (a potential moderator of alcohol-related self-aggression). Independent alcohol and model effects were found, with alcohol accounting for over 30% of the self-aggression variance.
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Affiliation(s)
- Michael S McCloskey
- Department of Psychology, University of Southern Mississippi, Hattiesburg 39406-5025, USA.
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Escobedo LG, Ortiz M. The relationship between liquor outlet density and injury and violence in New Mexico. ACCIDENT; ANALYSIS AND PREVENTION 2002; 34:689-694. [PMID: 12214963 DOI: 10.1016/s0001-4575(01)00068-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
This study used an ecologic design based on data from 1990 to 1994 gathered from forensic, vital statistic, census, law enforcement and liquor licensing agencies to assess the relationship between liquor outlet density and alcohol-related health outcomes in New Mexico. Linear regression models show that suicide, alcohol-related crash, and alcohol-related crash fatality (adjusted for age, sex, and minority status) are significantly associated with liquor outlet density. Data also show that, compared with the first tertile, suicide and alcohol-related crash rates increase about 50% and the alcohol-related crash fatality rate two-fold with the third tertile of liquor outlet density. Greater availability of liquor outlets is associated with higher rates of suicide, alcohol-related crash, and alcohol-related crash fatality.
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Stewart SE, Manion IG, Davidson S. Emergency management of the adolescent suicide attempter: a review of the literature. J Adolesc Health 2002; 30:312-25. [PMID: 11996780 DOI: 10.1016/s1054-139x(01)00321-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- S Evelyn Stewart
- Department of Psychiatry, University of Ottawa, Ottawa, Ontario, Canada
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Abstract
Most instances of hepatotoxicity due to paracetamol in the United Kingdom and Australia are the result of large overdoses of the drug taken with suicidal or parasuicidal intent. In contrast, serious hepatotoxicity at recommended or near-recommended doses for therapeutic purposes has been reported, mainly from the United States and in association with chronic alcohol use, leading to the widely held belief that chronic alcoholics are predisposed to paracetamol-related toxicity at relatively low doses. Yet the effects of alcohol on paracetamol metabolism are complex. Studies performed in both experimental animals and humans indicate that chronic alcohol use leads to a short-term, two- to threefold increase in hepatic content of cytochrome P4502E1, the major isoform responsible for the generation of the toxic metabolite from paracetamol, although increased oxidative metabolism of paracetamol at recommended doses has not been demonstrated clinically. A reduced hepatic content of glutathione, required to detoxify the reactive metabolite, has been documented in chronic alcoholics, due probably to associated fasting and malnutrition, providing a metabolic basis for any possible predisposition of this group to hepatotoxicity at relatively low paracetamol doses. Simultaneous alcohol and paracetamol ingestion reduces oxidative metabolism of paracetamol in both rodents and humans, predominantly as a consequence of depletion in cytosol of free NADPH. The possibilities that chronic alcohol use may predispose to paracetamol-related hepatotoxicity and that alcohol taken with paracetamol may protect against it, based on these metabolic observations, are examined in this review.
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Affiliation(s)
- Stephen M Riordan
- Gastrointestinal and Liver Unit, The Prince of Wales Hospital and University of New South Wales, Sydney, Australia
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Abstract
The annual rate of suicide in Dubai between 1992 and 2000 was 6.2/100,000. There was a non- significant peak incidence in November while July recorded the lowest incidence. Fridays showed the lowest incidence with no significant difference between Muslims and non-Muslims. Victims were predominantly male expatriates with no significant difference between Muslims and non-Muslims. However, a significant increase in the number of non-Indian female expatriates was recorded. The majority of victims were of the age group 21-40 with a significant increase in teenaged females and teenaged citizens. Hanging was the commonest method for committing suicide. Females and non-Indian expatriates resorted significantly to jumping from a high and self-poisoning. The age of the victim had no effect on the choice of the method used to commit suicide. The majority of incidents took place in the victim's own house. A suicide note was left behind in 5% of cases. History of psychological illness or trauma was available in 9.7% of cases. In these cases, depressive illness and recent unemployment were the major triggers for suicidal impulse. A total of 27.7% of screened victims tested positive for alcohol and were predominantly males with no significant difference between Muslims and non-Muslims.
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Affiliation(s)
- Abbas A Koronfel
- Department of Forensic Medicine, Forensic Science Administration, Dubai Police General Headquarters, Dubai, United Arab Emirates
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