Prevalence of cocaine use among residents of New York City who committed suicide during a one-year period

Psychosocial interventions for stimulant use disorder

BACKGROUND

Stimulant use disorder is a continuously growing medical and social burden without approved medications available for its treatment. Psychosocial interventions could be a valid approach to help people reduce or cease stimulant consumption. This is an update of a Cochrane review first published in 2016.

OBJECTIVES

To assess the efficacy and safety of psychosocial interventions for stimulant use disorder in adults.

SEARCH METHODS

We searched the Cochrane Drugs and Alcohol Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, three other databases, and two trials registers in September 2023. All searches included non-English language literature. We handsearched the references of topic-related systematic reviews and the included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing any psychosocial intervention with no intervention, treatment as usual (TAU), or a different intervention in adults with stimulant use disorder.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included a total of 64 RCTs (8241 participants). Seventy-three percent of studies included participants with cocaine or crack cocaine use disorder; 3.1% included participants with amphetamine use disorder; 10.9% included participants with methamphetamine use disorder; and 12.5% included participants with any stimulant use disorder. In 18 studies, all participants were in methadone maintenance treatment. In our primary comparison of any psychosocial treatment to no intervention, we included studies which compared a psychosocial intervention plus TAU to TAU alone. In this comparison, 12 studies evaluated cognitive behavioural therapy (CBT), 27 contingency management, three motivational interviewing, one study looked at psychodynamic therapy, and one study evaluated CBT plus contingency management. We also compared any psychosocial intervention to TAU. In this comparison, seven studies evaluated CBT, two contingency management, two motivational interviewing, and one evaluated a combination of CBT plus motivational interviewing. Seven studies compared contingency management reinforcement related to abstinence versus contingency management not related to abstinence. Finally, seven studies compared two different psychosocial approaches. We judged 65.6% of the studies to be at low risk of bias for random sequence generation and 19% at low risk for allocation concealment. Blinding of personnel and participants was not possible for the type of intervention, so we judged all the studies to be at high risk of performance bias for subjective outcomes but at low risk for objective outcomes. We judged 22% of the studies to be at low risk of detection bias for subjective outcomes. We judged most of the studies (69%) to be at low risk of attrition bias. When compared to no intervention, we found that psychosocial treatments: reduce the dropout rate (risk ratio (RR) 0.82, 95% confidence interval (CI) 0.74 to 0.91; 30 studies, 4078 participants; high-certainty evidence); make little to no difference to point abstinence at the end of treatment (RR 1.15, 95% CI 0.94 to 1.41; 12 studies, 1293 participants; high-certainty evidence); make little to no difference to point abstinence at the longest follow-up (RR 1.22, 95% CI 0.91 to 1.62; 9 studies, 1187 participants; high-certainty evidence); probably increase continuous abstinence at the end of treatment (RR 1.89, 95% CI 1.20 to 2.97; 12 studies, 1770 participants; moderate-certainty evidence); may make little to no difference in continuous abstinence at the longest follow-up (RR 1.14, 95% CI 0.89 to 1.46; 4 studies, 295 participants; low-certainty evidence); reduce the frequency of drug intake at the end of treatment (standardised mean difference (SMD) -0.35, 95% CI -0.50 to -0.19; 10 studies, 1215 participants; high-certainty evidence); and increase the longest period of abstinence (SMD 0.54, 95% CI 0.41 to 0.68; 17 studies, 2118 participants; high-certainty evidence). When compared to TAU, we found that psychosocial treatments reduce the dropout rate (RR 0.79, 95% CI 0.65 to 0.97; 9 studies, 735 participants; high-certainty evidence) and may make little to no difference in point abstinence at the end of treatment (RR 1.67, 95% CI 0.64 to 4.31; 1 study, 128 participants; low-certainty evidence). We are uncertain whether they make any difference in point abstinence at the longest follow-up (RR 1.31, 95% CI 0.86 to 1.99; 2 studies, 124 participants; very low-certainty evidence). Compared to TAU, psychosocial treatments may make little to no difference in continuous abstinence at the end of treatment (RR 1.18, 95% CI 0.92 to 1.53; 1 study, 128 participants; low-certainty evidence); probably make little to no difference in the frequency of drug intake at the end of treatment (SMD -1.17, 95% CI -2.81 to 0.47, 4 studies, 479 participants, moderate-certainty evidence); and may make little to no difference in the longest period of abstinence (SMD -0.16, 95% CI -0.54 to 0.21; 1 study, 110 participants; low-certainty evidence). None of the studies for this comparison assessed continuous abstinence at the longest follow-up. Only five studies reported harms related to psychosocial interventions; four of them stated that no adverse events occurred.

AUTHORS' CONCLUSIONS

This review's findings indicate that psychosocial treatments can help people with stimulant use disorder by reducing dropout rates. This conclusion is based on high-certainty evidence from comparisons of psychosocial interventions with both no treatment and TAU. This is an important finding because many people with stimulant use disorders leave treatment prematurely. Stimulant use disorders are chronic, lifelong, relapsing mental disorders, which require substantial therapeutic efforts to achieve abstinence. For those who are not yet able to achieve complete abstinence, retention in treatment may help to reduce the risks associated with stimulant use. In addition, psychosocial interventions reduce stimulant use compared to no treatment, but they may make little to no difference to stimulant use when compared to TAU. The most studied and promising psychosocial approach is contingency management. Relatively few studies explored the other approaches, so we cannot rule out the possibility that the results were imprecise due to small sample sizes.

Prevalence and risk factors associated with psychostimulant use among Black individuals: A meta-analysis and systematic review

BACKGROUND

Psychostimulants (e.g., cocaine, amphetamine) are among the most widely used drugs globally with detrimental short and long-term physical, psychological and social consequences. There is limited data on psychostimulant use for various racial and ethnic groups, including Black people, and the challenges they face living as minorities overcoming historical challenges including increased incarceration associated with drug possession.

METHODS

Peer-reviewed articles were identified in five databases (APA PsycInfo, CINAHL, Cochrane CENTRAL, Embase, MEDLINE). Eligible studies were published in French or English, provided empiral data on psychostimulant use in Black individuals living in a minority context. The PRISMA guideline was used for structuring the review. Random-effects meta-analyses were generated to estimate the pooled prevalence of lifetime and periodic psychostimulant use among Black individuals using STATA 16.

RESULTS

Sixty-three studies published from 1991 to 2022 with a sample size of 139,683 Black individuals were included in the current meta-analysis. Results indicate a pooled prevalence estimate of 11.4% for any form of psychostimulant use among Black individuals. The pooled prevalence estimates were 12.4% (95% CI, 8.4% - 16.4%) for cocaine, 8.3% (95% CI, 0% - 19.1%) for amphetamines, and 11.4% (95% CI, 4.6% - 18.1%) for other stimulants. Prediction intervals for all psychostimulant types were highly heterogenous ranging from 0% to as high as 51.2% for amphetamine suggesting prevalence of use in some studies of Black people could be found to be as low as zero. Subgroup analyses were conducted to examine differences between age groups, gender, reference period, and type of assessment.

CONCLUSIONS

High prevalence rates of psychostimulant use among Black people argues for greater access to evidence-based treatments. However, current psychosocial interventions are suboptimal, warranting further study. Consideration needs to be given to the challenges of the large range of prediction intervals, living in urban areas, racial discrimination experiences, race-based stress, and sociodemographic characteristics, including poverty, education level, age, gender.

Exploring protective associations between the use of classic psychedelics and cocaine use disorder: a population-based survey study

Cocaine Use Disorder (CUD) is a significant public health problem associated with elevated morbidity and mortality within the United States. Current behavioral treatments have limited efficacy and there are currently no FDA approved pharmacological treatments for CUD. Classic psychedelics might be associated with lowered odds of substance misuse and may effectively treat various forms of addiction. Thus, the goal of this study is to assess protective associations that lifetime use of classic psychedelics may share with CUD within a nationally representative sample of the U.S. We used data from The National Survey on Drug Use and Health (NSDUH) (2015–2019) and conducted survey-weighted multivariable logistic regression to test whether each of four classic psychedelics (peyote, mescaline, psilocybin, LSD) conferred lowered odds of CUD and its related 11 sub-criteria. Participants were 214,505 adults in the NSDUH (2015–2019) aged 18 and older. Peyote conferred lowered odds of CUD, reducing the odds of CUD by over 50% (aOR: 0.47). All other substances (including other classic psychedelics) either shared no association to CUD or conferred increased odds of CUD. Furthermore, sensitivity analyses revealed peyote to confer sharply lowered odds of the majority (seven of 11) of CUD criteria as well (aOR range: 0.26–0.47). Peyote use is associated with lowered odds of CUD. Future inquiries into third variable factors (i.e., demographic/personality profiles of individuals who use peyote, motivational/contextual factors surrounding peyote use) that may underlie our observed associations may reveal protective factors that can inform treatment development for CUD. Additionally, future longitudinal studies can shed further light on whether there is a temporal link between peyote use and lowered odds of CUD.

Mortality Trends among Cocaine Users Treated between 1989 and 2013 in Northern Italy: Results of a Longitudinal Study

A total of 852 participants attending 11 centers for addiction treatment in north Italy following problems due to cocaine abuse between 1989 and 2013 were recruited. Two typologies were created: cocaine users (never heroin) (CU) and heroin and cocaine users (HCU). During the 38-year follow-up period, 4.8% of the whole cohort died. Over the whole period, tumors were the main causes of death; starting in 2010, suicide deaths became the first cause of death. Among CUs, most deaths were due to road accidents and suicide; among HCUs, most of the deaths were from opiate overdose and from cardio-circulatory system diseases. The excess mortality observed for all causes in either sex was 6.24; higher in females (15.03) as compared in males (6.23), higher in HCUs (9.06) as compared in CUs (5.21). The directly age-sex standardized mortality rates were 5.31 per 100, higher for females, declining after 2009 for all patients and after 2004 for HCUs. Multivariate analysis confirms the decreasing trend in the risk of death and shows a higher mortality risk for participants in the under-25 age group. Among cocaine users, special attention should be paid to the prevention of suicide deaths.

Treatment-refractory substance use disorder: Focus on alcohol, opioids, and cocaine

Substance use disorders are common, but only a small minority of patients receive adequate treatment. Although psychosocial therapies are effective, relapse is common. This review focusses on novel pharmacological and other treatments for patients with alcohol, opioid, or cocaine use disorders who do not respond to conventional treatments. Disulfiram, acamprosate, and the opioid antagonist naltrexone have been approved for the treatment of alcoholism. A novel, "as needed" approach is the use of the mu-opioid antagonist and partial kappa agonist nalmefene to reduce alcohol consumption. Other novel pharmacological approaches include the GABA-B receptor agonist baclofen, anticonvulsants such as topiramate and gabapentin, the partial nicotine receptor agonist varenicline, and other drugs. For opioid dependence, opioid agonist therapy with methadone or buprenorphine is the first-line treatment option. Other options include oral or depot naltrexone, morphine sulfate, depot or implant formulations, and heroin (diacetylmorphine) in treatment-refractory patients. To date, no pharmacological treatment has been approved for cocaine addiction; however, 3 potential pharmacological treatments are being studied, disulfiram, methylphenidate, and modafinil. Pharmacogenetic approaches may help to optimize treatment response in otherwise treatment-refractory patients and to identify which patients are more likely to respond to treatment, and neuromodulation techniques such as repeated transcranial magnetic stimulation and deep brain stimulation also may play a role in the treatment of substance use disorders. Although no magic bullet is in sight for treatment-refractory patients, some novel medications and brain stimulation techniques have the potential to enrich treatment options at least for some patients.

Psychosocial interventions for psychostimulant misuse

BACKGROUND

Psychostimulant misuse is a continuously growing medical and social burden. There is no evidence proving the efficacy of pharmacotherapy. Psychosocial interventions could be a valid approach to help patients in reducing or ceasing drug consumption.

OBJECTIVES

To assess the effects of psychosocial interventions for psychostimulant misuse in adults.

SEARCH METHODS

We searched the Cochrane Drugs and Alcohol Group Specialised Register (via CRSLive); Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; CINAHL; Web of Science and PsycINFO, from inception to November 2015. We also searched for ongoing and unpublished studies via ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (apps.who.int/trialsearch/).All searches included non-English language literature. We handsearched references of topic-related systematic reviews and the included studies.

SELECTION CRITERIA

We included randomised controlled trials comparing any psychosocial intervention with no intervention, treatment as usual (TAU) or a different intervention in adults with psychostimulant misuse or dependence.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included a total of 52 trials (6923 participants).The psychosocial interventions considered in the studies were: cognitive behavioural therapy (19 studies), contingency management (25 studies), motivational interviewing (5 studies), interpersonal therapy (3 studies), psychodynamic therapy (1 study), 12-step facilitation (4 studies).We judged most of the studies to be at unclear risk of selection bias; blinding of personnel and participants was not possible for the type of intervention, so all the studies were at high risk of performance bias with regard to subjective outcomes; the majority of studies did not specify whether the outcome assessors were blind. We did not consider it likely that the objective outcomes were influenced by lack of blinding.The comparisons made were: any psychosocial intervention versus no intervention (32 studies), any psychosocial intervention versus TAU (6 studies), and one psychosocial intervention versus an alternative psychosocial intervention (13 studies). Five of included studies did not provide any useful data for inclusion in statistical synthesis.We found that, when compared to no intervention, any psychosocial treatment: reduced the dropout rate (risk ratio (RR): 0.83, 95% confidence interval (CI) 0.76 to -0.91, 24 studies, 3393 participants, moderate quality evidence); increased continuous abstinence at the end of treatment (RR: 2.14, 95% CI 1.27 to -3.59, 8 studies, 1241 participants, low quality evidence); did not significantly increase continuous abstinence at the longest follow-up (RR: 2.12, 95% CI 0.77 to -5.86, 4 studies, 324 participants, low quality evidence); significantly increased the longest period of abstinence: (standardised mean difference (SMD): 0.48, 95% CI 0.34 to 0.63, 10 studies, 1354 participants, high quality evidence). However, it should be noted that the in the vast majority of the studies in this comparison the specific psychosocial treatment assessed in the experimental arm was given in add on to treatment as usual or to another specific psychosocial or pharmacological treatment which was received by both groups. So, many of the control groups in this comparison were not really untreated. Receiving some amount of treatment is not the same as not receiving any intervention, so we could argue that the overall effect of the experimental psychosocial treatment could be smaller if given in add on to TAU or to another intervention than if given to participants not receiving any intervention; this could translate to a smaller magnitude of the effect of the psychosocial intervention when it is given in add on.When compared to TAU, any psychosocial treatment reduced dropout rate (RR: 0.72, 95% CI 0.59 to 0.89, 6 studies, 516 participants, moderate quality evidence), did not increase continuous abstinence at the end of treatment (RR: 1.27, 95% CI 0.94 to 1.72, 2 studies, 224 participants, low quality evidence), did not increase longest period of abstinence (MD -3.15 days, 95% CI -10.35 to 4.05, 1 study, 110 participants, low quality evidence). No studies in this comparison assessed the outcome of continuous abstinence at longest follow-up.There were few studies comparing two or more psychosocial interventions, with small sample sizes and considerable heterogeneity in terms of the types of interventions assessed. None reported significant results.None of the studies reported harms related to psychosocial interventions.

AUTHORS' CONCLUSIONS

The addition of any psychosocial treatment to treatment as usual (usually characterised by group counselling or case management) probably reduces the dropout rate and increases the longest period of abstinence. It may increase the number of people achieving continuous abstinence at the end of treatment, although this might not be maintained at longest follow-up. The most studied and the most promising psychosocial approach to be added to treatment as usual is probably contingency management. However, the other approaches were only analysed in a few small studies, so we cannot rule out the possibility that the results were not significant because of imprecision. When compared to TAU, any psychosocial treatment may improve adherence, but it may not improve abstinence at the end of treatment or the longest period of abstinence.The majority of the studies took place in the United States, and this could limit the generalisability of the findings, because the effects of psychosocial treatments could be strongly influenced by the social context and ethnicity. The results of our review do not answer the most relevant clinical question, demonstrating which is the most effective type of psychosocial approach.Further studies should directly compare contingency management with the other psychosocial approaches.

Examining the Complexities of Suicidal Behavior in the African American Community

Once considered a “White thing,” suicide is now the third leading cause of death for African Americans, behind only homicide and unintentional injury. Although the rates of suicide for African American women remain low and relatively unchanged, the rates for African American men have increased dramatically during the past 20 years. The changes in the suicide rates for African American youth have motivated researchers to investigate protective and risk factors associated with suicide. In light of some of the current findings that identify religious participation as a protective factor against suicide for African Americans, an alternative perspective is provided that examines the contribution of spirituality and specific religious practices on gender differences in suicide risk.

Characteristics of 61 Mexican American Adolescents Who Attempted Suicide

A total of 61 Mexican American adolescents who were consecutively admitted to an inpatient psychiatric unit after a suicide attempt were studied. They were given structured interviews to study their demographic, personal, and family characteristics. The intent of the suicide attempts was measured with the Pierce Suicide Intent Scale. Compared to subjects in the low-intent group, those in the high-intent group showed a history of more frequent previous suicide attempts (p < .03), had lived with both biological parents for a longer time (p < .04), usually had at least one biological parent at home at the time of the suicide attempts (p < .001), and had lived in the United States for a shorter period of time (p < .04). Psychosocialfactors including the phenomenon of acculturation are reviewed in the discussion of these results.

Association Between Substance Use and Gun-Related Behaviors

Gun-related violence is a public health concern. This study synthesizes findings on associations between substance use and gun-related behaviors. Searches through PubMed, Embase, and PsycINFO located 66 studies published in English between 1992 and 2014. Most studies found a significant bivariate association between substance use and increased odds of gun-related behaviors. However, their association after adjustment was mixed, which could be attributed to a number of factors such as variations in definitions of substance use and gun activity, study design, sample demographics, and the specific covariates considered. Fewer studies identified a significant association between substance use and gun access/possession than other gun activities. The significant association between nonsubstance covariates (e.g., demographic covariates and other behavioral risk factors) and gun-related behaviors might have moderated the association between substance use and gun activities. Particularly, the strength of association between substance use and gun activities tended to reduce appreciably or to become nonsignificant after adjustment for mental disorders. Some studies indicated a positive association between the frequency of substance use and the odds of engaging in gun-related behaviors. Overall, the results suggest a need to consider substance use in research and prevention programs for gun-related violence.

Postmortem Presence of Drugs and Method of Violent Suicide

The link between substance use and suicide is well established. However, little research analyzes how substance use is related to the method of suicide. This paper analyzes how specific drugs are associated with method of suicide, a critical topic because drug use bears on the etiology of suicide and may lead to policies aimed at deterring suicide. We use the COVDRS and logistic regression to examine postmortem presence of drugs among 3,389 hanging and firearm suicides in Colorado from 2004-2009. Net of demographic controls, we find that opiates are positively associated with firearms (OR: 1.92, 95% L: 1.27, 95% U: 2.86]) while antidepressants are positively associated with hanging (OR: 1.45, 95% L: 1.04, 95% U: 2.03). For cocaine and opiates, the association between drug use and violent method vary by educational attainment. Importantly, knowledge of the presence and type of specific drug is strongly associated with the method of suicide.

The global epidemiology and burden of psychostimulant dependence: findings from the Global Burden of Disease Study 2010

AIMS

To estimate the global prevalence of cocaine and amphetamine dependence and the burden of disease attributable to these disorders.

METHODS

An epidemiological model was developed using DisMod-MR, a Bayesian meta-regression tool, using epidemiological data (prevalence, incidence, remission and mortality) sourced from a multi-stage systematic review of data. Age, sex and region-specific prevalence was estimated for and multiplied by comorbidity-adjusted disability weightings to estimate years of life lost to disability (YLDs) from these disorders. Years of life lost (YLL) were estimated from cross-national vital registry data. Disability-adjusted life years (DALYs) were estimated by summing YLDs and YLLs in 21 regions, by sex and age, in 1990 and 2010.

RESULTS

In 2010, there were an estimated 24.1 million psychostimulant dependent people: 6.9 million cocaine and 17.2 million amphetamines, equating to a point prevalence of 0.10% (0.09-0.11%) for cocaine, and 0.25% (0.22-0.28%) for amphetamines. There were 37.6 amphetamine dependence DALYs (21.3-59.3) per 100,000 population in 2010 and 15.9 per 100,000 (9.3-25.0) cocaine dependence DALYs. There were clear differences between amphetamines and cocaine in the geographic distribution of crude DALYs. Over half of amphetamine dependence DALYs were in Asian regions (52%), whereas almost half of cocaine dependence DALYs were in the Americas (44%, with 23% in North America High Income).

CONCLUSION

Dependence upon psychostimulants is a substantial contributor to global disease burden; the contribution of cocaine and amphetamines to this burden varies dramatically by geographic region. There is a need to scale up evidence-based interventions to reduce this burden.

Gender and racial differences for suicide attempters and ideators in a high-risk community corrections population

BACKGROUND

Community corrections populations are a high-risk group who carry multiple suicide risk factors.

AIMS

To identify factors correlated with historical suicide attempts and ideation among African-American men, African-American women, White men, and White women in a community corrections population.

METHOD

Self-report data from 18,753 enrollees in community corrections were analyzed. Multinomial logistic regression analyses were conducted to determine associations between historical suicidal ideation and attempts among the four demographic groups.

RESULTS

Participants with historical suicide attempts tended to be younger, White, female, be taking psychotropic medication, have a history of physical or sexual abuse, and meet criteria for dependence on alcohol, amphetamines, cocaine, opioids, or sedatives. Five variables were commonly associated with suicide attempts for all four race/gender groups: younger age, being on disability or retirement, taking psychotropic medication, history of sexual or physical abuse, and cocaine dependence. Other demographic variables had race or gender specificities as risk factors for suicide attempts.

CONCLUSIONS

Participants had high rates of historical suicide attempts with unique correlates differentiating attempters from ideators among different racial and gender groups. Cocaine dependence was universal predictor of suicide attempts, while other substance dependencies show specific racial and gender profiles associated with suicide attempts.

Factors that affect substance users' suicidal behavior: a view from the Addiction Severity Index in Korea

BACKGROUND

In South Korea, it has not been easy to negotiate studies that target drug users who are being punished by law, and accordingly, no study on suicidal ideation among substance users has been accomplished yet. In this study, the factors that affect substance users' suicidal ideation were confirmed.

METHODS

It was based on the data collected from 'The 2009 Study on Substance-Dependent Individuals in Korea' , which was conducted by The Catholic University of Korea in 2010 as a project sponsored by the Ministry of Health and Welfare of Korea. This study targeted 523 former hospital inpatients, prison inmates, and persons under protective supervision who had used substances such as psychotropic drugs, marijuana, and narcotic agents, and were in the recovery stage at various treatment/rehabilitation centers. Student's t and chi-square tests were used, and multivariate analysis was performed to examine the strength of the relationships between suicide ideation and various factors.

RESULTS

According to this study, 41% of these substance users planned suicide with suicidal ideation. Suicidal ideation was confirmed as associated with an unsatisfactory domestic environment, insufficient and unsatisfactory spare time experiences with others, emotional abuse, severe depression, and trouble with controlling violent behavior. Of the substance users who had planned to commit suicide, 56% attempted suicide. Their suicide attempts were shown to have been associated with insufficient protective supervision and the experiences of physical abuse, trouble with controlling violent behavior, and doctors' prescriptions due to psychological or emotional problems.

CONCLUSION

Based on this analysis of the factors that affect suicidal behavior, preventive measures and strategies for substance user were suggested in this study.

Gender differences in the presence of drugs in violent deaths

AIMS

To investigate differences in the presence of drugs, by gender, when considering deaths attributable to homicides and suicides.

DESIGN

Logistic regression analysis of mortality data collected by the Colorado Violent Death Reporting System.

PARTICIPANTS AND SETTING

A total of 5791 Colorado decedents who died of violent causes from 2004 to 2009.

MEASUREMENT

Forensic pathologist autopsy data on drug presence at time of death, coded as present, not present or missing.

FINDINGS

Postmortem presence of drugs is associated strongly with the specific cause of violent death. Compared with suicide decedents, homicide decedents are significantly more likely to test positive for amphetamines [odds ratio (OR): 1.79; confidence interval (CI): 1.34, 2.39], marijuana (OR: 2.03; CI: 1.60, 2.58) and cocaine (OR: 2.60; CI: 2.04, 3.31), and are less likely to test positive for opiates (OR: 0.27; CI: 0.18, 0.39) and antidepressants (OR: 0.17; CI: 0.10, 0.28). When other drugs are controlled for the influence of alcohol is abated dramatically. The patterns of drug prevalence associated with homicide (particularly marijuana) are stronger among males; the patterns of drug prevalence associated with suicide are stronger among females.

CONCLUSIONS

Suicide and homicide decedents are characterized by varying patterns of licit and illicit drug use that differ by gender. Drugs associated with homicide (marijuana, cocaine and amphetamines) are stronger among males, while drugs associated with suicide are stronger among females (antidepressants and opiates). Taking these differences into consideration may allow for targeted interventions to reduce violent deaths.

Cocaine use in the past year is associated with altitude of residence

OBJECTIVES

Recently, increased rates of suicide in US counties at higher altitudes have been noted. Because of the documented association between cocaine use and suicide, we hypothesized that there would be a correlation between incidence of cocaine use and altitude of residence.

METHODS

Cocaine use data were obtained from the Substate Substance Abuse Estimates from the 1999-2001 National Surveys on Drug Use and Health. Data related to the percentages of people 12 years or older who used cocaine in the past year. Average elevation for US counties was calculated using the Shuttle Radar Topography Mission elevation data set, and subject region elevation was calculated by averaging the weighted elevations of each region's relevant counties. The correlation between elevation of a substate region and incidence of cocaine use in that region was calculated using Pearson correlation coefficients.

RESULTS

A significant correlation exists between mean altitude of a substate region and incidence of cocaine use in that region (r = 0.34; P < 0.0001). Regression analysis controlling for age, sex, race, education level, income, unemployment, and population density was performed. Altitude remained a significant factor (P = 0.007), whereas male sex (P = 0.008) and possessing less than a college education (P < 0.0001) were also significant predictors of self-reported cocaine use in the past year. It is important to note that cocaine use was assessed in isolation of other drugs of abuse, an additional confounding variable.

CONCLUSIONS

This study demonstrates a significant correlation between altitude of substate region of residence and incidence of cocaine use. It is possible that stress response due to hypoxia is responsible; however, this requires further investigation. However, because other substance use was not assessed, specificity of this association is unknown. In addition, this correlation may help explain the increased rate of suicide in areas of higher elevation.

Substance abuse and suicide risk among adolescents

The aim of this paper was to review the literature concerning the relationship between suicide and substance abuse behaviours among adolescents, focusing on epidemiology, comorbidity and preventive programmes. We performed a Pubmed/Medline, Scopus, PsycLit and PsycInfo search to identify all papers and book chapters during the period between 1980 and 2011. Adolescents with substance abuse disorder who attempt or complete suicide can be characterized as having mood disorders, stressful life events, interpersonal problems, poor social support, lonely lives and feelings of hopelessness. The research supports the existence of a strong relationship between suicide and substance abuse. Preventive programmes should be based on the detection of risk factors associated with both suicide and substance abuse disorder. Management programmes should combine different therapeutic strategies such as peer-to-peer education, school-based programmes, psychotherapy and pharmacological treatment. Evidence suggests that targeted suicide prevention programmes can be delivered which reduce the burden associated with substance abuse and suicide in youths.

Parental grief after a child's drug death compared to other death causes: investigating a greatly neglected bereavement population

This comparative survey contrasted 571 parents who lost children to various death causes: 48 to drug-related deaths and overdoses, 462 to suicide, 24 to natural death cases, and 37 to mostly accidental death cases. Groups were compared in terms of grief difficulties, mental health problems, posttraumatic stress, and stigmatization. Results did not show any appreciable differences in these respects between the suicide bereaved parents and those losing children to drug-related deaths. However, when the suicide and drug-related death survivors were specifically contrasted against accidental and natural death loss cases, a consistent pattern emerged showing the former group was consistently more troubled by grief and mental health problems than the latter two sub-groups. These differences remained when controls of time since the loss and gender differences were employed as covariates. These findings suggest that the powerful and intense stigma against drug use and mental illness, shared among the public-at-large, imposes challenges in healing of immense proportion for these parents as they find less compassionate responses from their significant others, following their losses.

What data are available on the extent of illicit drug use and dependence globally? Results of four systematic reviews

BACKGROUND

We systematically reviewed availability and quality of data on the prevalence of use and dependence on meth/amphetamine, cannabis, cocaine and opioids.

METHODS

Multiple search strategies: (a) peer-reviewed literature searches (1990-2008) using methods recommended by the Meta-analysis of Observational Studies in Epidemiology (MOOSE) group; (b) systematic searches of online databases; (c) Internet searches to find other published evidence of drug use; (d) repeated consultation and feedback from experts around the globe; (e) a viral email sent to lists of researchers in the illicit drug and HIV fields. Data were extracted and graded according to predefined variables reflecting quality of data source.

RESULTS

Qualitative evidence of illicit drug use and dependence was found for most countries, which hold over 98% of the world's population aged 15-64 years. Countries where use was identified but prevalence estimates had not been made (evidence of drug supply, trafficking, reports of use, treatment data) were mainly from Asia, Africa, the Middle East, and Oceania. Estimates of the prevalence of use were located in 77 countries for meth/amphetamine, 95 for cannabis, 86 for cocaine and 89 for opioids. Dependence prevalence estimates existed in very few countries; 9 meth/amphetamine dependence estimates, 7 cannabis dependence estimates, 5 cocaine dependence estimates, and 25 opioid dependence estimates were located.

CONCLUSIONS

Data on the extent of meth/amphetamine, cannabis, cocaine and opioid use and dependence must be improved in quality and coverage. Dependence estimates are lacking even in high income countries that have required resources. Responses to illicit drug dependence require better estimates of its scale.

kappa-Opioid receptor signaling and brain reward function

The dynorphin-like peptides have profound effects on the state of the brain reward system and human and animal behavior. The dynorphin-like peptides affect locomotor activity, food intake, sexual behavior, anxiety-like behavior, and drug intake. Stimulation of kappa-opioid receptors, the endogenous receptor for the dynorphin-like peptides, inhibits dopamine release in the striatum (nucleus accumbens and caudate putamen) and induces a negative mood state in humans and animals. The administration of drugs of abuse increases the release of dopamine in the striatum and mediates the concomitant release of dynorphin-like peptides in this brain region. The reviewed studies suggest that chronic drug intake leads to an upregulation of the brain dynorphin system in the striatum and in particular in the dorsal part of the striatum/caudate putamen. This might inhibit drug-induced dopamine release and provide protection against the neurotoxic effects of high dopamine levels. After the discontinuation of chronic drug intake these neuroadaptations remain unopposed which has been suggested to contribute to the negative emotional state associated with drug withdrawal and increased drug intake. kappa-Opioid receptor agonists have also been shown to inhibit calcium channels. Calcium channel inhibitors have antidepressant-like effects and inhibit the release of norepinephrine. This might explain that in some studies kappa-opioid receptor agonists attenuate nicotine and opioid withdrawal symptomatology. A better understanding of the role of dynorphins in the regulation of brain reward function might contribute to the development of novel treatments for mood disorders and other disorders that stem from a dysregulation of the brain reward system.

Characteristics of cocaine dependent patients who attempt suicide

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

Substance-induced suicidal admissions to an acute psychiatric service: Characteristics and outcomes

The degree of substance-induced syndrome (SIS) was evaluated in 5,116 acutely hospitalized suicidal psychiatric inpatients. Admission and discharge severity ratings were made by academic attendings using structured forms. Outcome variables analyzed include ratings of psychiatric symptom severity on admission and discharge, length of stay, severity of SIS, and severity of alcohol/drug problems. Suicidal inpatients rated with a high degree of SIS were more likely to be homeless, to be unemployed, to be uncooperative, to have shorter lengths of stay, and to show a more rapid improvement in symptoms. These patients represent a subgroup of the co-occurring disorders population having a high degree of addiction severity with temporary substance-induced suicidal syndromes and are subjected to the most expensive level of care in the mental health system. Implications of these findings include the fact that psychiatric inpatient services need to provide intensive addiction intervention treatment and that outpatient addiction services need improved capability and capacity to care for suicidal patients.

Interaction between childhood trauma and serotonin transporter gene variation in suicide

Although the serotonin transporter promoter polymorphism (5-HTTLPR) contributes to depression and suicidality in a fashion modulated by environmental stress, 5-HTTLPR has been little examined in relation to suicidal behavior in substance dependence. Recently, a third functional allele of 5-HTTLPR was discovered enabling more of the interindividual variation in serotonin transporter expression to be predicted by genotype. We examined whether the 5-HTTLPR gene alone, or interacting with childhood trauma, was predictive of suicidal behavior in substance-dependent patients, a clinical population that is at high risk of suicide, as well as childhood trauma and other stress. We interviewed 306 abstinent male African-American substance-dependent patients about whether they had ever attempted suicide and administered the 34-item Childhood Trauma Questionnaire (CTQ). Patients and 132 male African-American controls were genotyped to determine the S, L(G), and L(A) 5-HTTLPR alleles; some analyses grouped the S and L(G) alleles on the basis of equivalent function. The distribution of 5-HTTLPR genotypes did not differ between patients and controls, nor between suicide attempters and non-attempters. However, patients with low expression 5-HTTLPR genotypes and above-median CTQ scores were more likely to have attempted suicide. Logistic regression showed increasing risk of a suicide attempt with increasing reports of childhood trauma scores; in addition, this increase was exaggerated among those with low expression forms of the 5-HTTLPR genotype. Childhood trauma interacts with low expressing 5-HTTLPR genotypes to increase the risk of suicidal behavior among patients with substance dependence.

New developments in the pharmacotherapy of cocaine abuse

Despite huge advances in the neuroscience of substance abuse and dependence in the past 20 years, no approved pharmacological treatment exists for cocaine abuse. The available drugs for the treatment of cocaine abuse are poorly effective, hence the need for new compounds to be screened and tested for efficacy: targeting symptoms might improve the effectiveness of the treatment of cocaine abuse and dependence. On the basis of the known neurochemistry of cocaine, some target compounds have been studied: among others, BP-897, a D3 partial agonist; vanoxerine, a highly selective inhibitor of dopamine uptake; aripiprazole, a partial mixed-action agonist approved for the treatment of schizophrenia. Recently modafinil, approved for the treatment of narcolepsy, proved effective in favouring cocaine abstinence in cocaine-abusing people. Some placebo-controlled studies also reported the effectiveness of topiramate, a licensed antiepileptic drug, and of tiagabine, a gamma-aminobutyric acid (GABA) re-uptake inhibitor also approved as an anticonvulsant; both compounds increased cocaine abstinence with no serious adverse events. Promising results came from two more compounds acting on the GABA circuits, baclofen and valproic acid. Finally disulfiram, prescribed with active psychosocial therapy, was found to favour higher retention rates and longer abstinence periods from both alcohol and cocaine in polydrug-abusing patients. An alternative approach rests on the use of vaccines, to date in the experimental stage still. Psychosocial treatments are a useful companion in the pharmacotherapy of cocaine abuse, with group therapy and contingency management therapies improving motivation and social functioning, particularly in patients abusing alcohol as well.

"Excessive tears": a diagnostic sign for cocaine-induced mood disorder?

OBJECTIVE

This study aims to investigate excessive tearfulness as a sign to help determine the etiology of depressive symptoms.

METHODS

Clinicians were instructed to document the occurrence of excessive tearfulness in all patients seen in the Psychiatric Emergency Service. Excessive tearfulness was defined as crying to the severity that at least 1 tear drops off the face. A comparison group was formed from the general population of the Psychiatric Emergency Service.

RESULTS

Excessive tearfulness was documented in 36 different patients. The prevalence of the sign in the general population was 1.9%. Patients with excessive tearfulness were more likely to have cocaine in their urine (P < .0001, chi(2) test), receive a substance-related primary diagnosis (P < .0001, chi(2) test), and be admitted for psychiatric hospitalization (P < .001 chi(2) test). Patients with excessive tearfulness had significantly shorter voluntary hospital stays (P < .05, t test).

CONCLUSION

Excessive tearfulness could be a useful clinical sign of cocaine-induced depression.

Differences in risk factors for suicidality between African American and White patients vulnerable to suicide

Risk factors for suicidal ideation and attempts have been shown to differ between African Americans and Whites across the lifespan. In the present study, risk factors for suicidality were examined separately by race/ethnicity in a population of 131 older adult patients considered vulnerable to suicide due to substance abuse and/or medical frailty. In adjusted analyses, social support was significantly associated with suicidality in African American patients, while younger age and the presence of an anxiety disorder were significantly associated with suicidality in White patients. The results suggest that race/ethnicity-specific risk profiles may improve the detection of suicidality in vulnerable populations.

Race/ethnicity, substance abuse, and mental illness among suicide victims in 13 US states: 2004 data from the National Violent Death Reporting System

OBJECTIVE

To calculate the prevalence of substance abuse and mental illness among suicide victims of different racial/ethnic groups and to identify race/ethnicity trends in mental health and substance abuse that may be used to improve suicide prevention.

METHODS

Data are from the National Violent Death Reporting System (NVDRS), a state-based data integration system that, for 2004, includes data from 13 US states. The NVDRS integrates medical examiner, toxicology, death certificate, and law enforcement data.

RESULTS

Within participating states, for data year 2004, 6865 suicide incidents in which race/ethnicity are known were identified. This included 5797 (84.4%) non-Hispanic whites, 501 (7.3%) non-Hispanic blacks, 257 (3.7%) Hispanics, and 310 (4.5%) persons from other racial/ethnic groups. At the time of the suicide event, non-Hispanic blacks had lower blood alcohol contents than other groups. Non-Hispanic whites had less cocaine but more antidepressants and opiates. There were no differences in the levels of amphetamines or marijuana by race/ethnicity. Hispanics were less likely to have been diagnosed with a mental illness or to have received treatment, although family reports of depression were comparable to non-Hispanic whites and other racial/ethnic groups. Non-Hispanic whites were more likely to be diagnosed with depression or bipolar disorder and non-Hispanic blacks with schizophrenia. Comorbid substance abuse and mental health problems were more likely among non-Hispanic whites and non-Hispanic blacks, while Hispanics were more likely to have a substance abuse problem without comorbid mental health problems.

CONCLUSION

The results support earlier research documenting differences in race/ethnicity, substance abuse, and mental health problems as they relate to completed suicide. The data suggest that suicide prevention efforts must address not only substance abuse and mental health problems in general, but the unique personal, family, and social characteristics of different racial/ethnic groups.

Explaining Changes in the Patterns of Black Suicide in the United States From 1981 to 2002: An Age, Cohort, and Period Analysis

To explore the different trends of suicide incidence among Blacks and possible contributing factors, the current study compared national epidemiologic data of suicide in the United States from 1981 to 2002. For the first time, period and birth-cohort effects on the incidence trends of Black suicide were evaluated using an age-period-cohort analysis. Cohort effects were found for males and females, suggesting that younger generations of Blacks are at higher risk. If younger cohorts carry their increased suicide risk into later life, then the recent decline in Black suicide rates will be reversed. The results of the current study are only interpretable in terms of group-level characteristics and population suicide rates and not individual-level characteristics. The possible explanation and the implications for prevention and future research are discussed.

Predictors of high rates of suicidal ideation among drug users

Several studies have attempted to understand the link among substance abuse, depression, and suicidal ideation (SI). Assessment of this link is important to develop specific interventions for persons in substance abuse treatment. This association was tested among 990 drug users in and out of treatment with significant criminal justice histories from two National Institute on Drug Abuse studies. The Diagnostic Interview Schedule and Substance Abuse Module assessed DSM-III-R depression, number of depression criteria met, antisocial personality disorder (ASPD), and substance use disorders. Compared with men, women were twice as likely to report depression (24% vs. 12%), whereas men were nearly twice as likely to report ASPD (42% vs. 24%). High rates of SI were found, with women more likely than men to report thoughts of death (50% vs. 31%), wanting to die (39% vs. 21%), thoughts of committing suicide (47% vs. 33%), or attempting suicide (33% vs. 11%); 63% of women and 47% of men reported at least one of these suicidal thoughts or behaviors. Male and female ideators were more likely than nonideators to report depressed mood and to meet criteria for depression, ASPD, and alcohol use disorders. Male ideators were more likely than male nonideators to meet criteria for cocaine use disorders. Using logistic regression, SI among men was predicted by alcohol use disorder (OR = 1.60), ASPD (OR = 1.59), and number of depression criteria (OR = 9.38 for five criteria). Among women, SI was predicted by older age, marital status, alcohol use disorder (OR = 2.77), and number of depression criteria (OR = 9.12 for five criteria). These original findings point out the need to discuss suicidal thoughts among depressed drug users for early treatment and prevention.

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

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.

Person Factors Associated With Suicidal Behavior Among African American Women and Men

This study compared person risk factors among the following groups of low-income, African American adults in an urban, public hospital: (a) suicide attempters and nonattempters, (b) male and female attempters, and (c) all 4 groups (50 female attempters, 50 female nonattempters, 50 male attempters, and 50 male nonattempters). Participants completed psychological distress, aggression, substance use, cognitive processes, religiosity/spirituality, and ethnic identity measures. Compared with nonattempters, attempters reported more psychological distress, aggression, substance use, and maladaptive coping strategies; less religiosity/spirituality; and lower levels of ethnic identity. Male attempters endorsed more substance use than female attempters. No person risk factors differentiated among the 4 groups. Assessment of person risk factors and implementation of commensurate culturally competent interventions are recommended.

Monoamine transporters and psychostimulant drugs

Most psychostimulants interact with monoamine transport proteins. This paper reviews work our laboratory has conducted to investigate the interaction of psychostimulants with monoamine transporters in order to advance our understanding of how these drugs affect the brain. We review two topics: (1) characterization of multiple binding sites for cocaine-like drugs and (2) an examination of the mechanisms of action of amphetamine-type anorectic agents. We conclude that the brain contains high abundance nonclassical binding sites for cocaine-like drugs that have micromolar affinity for cocaine and that none of the clinically available amphetamine-type appetite suppressants are equipotent substrates for dopamine transporter (DAT) and serotonin transporter (SERT) proteins. Future medications discovery efforts should focus on identifying new compounds which possess the equipotent substrate activity at DAT and SERT, but which lack the adverse effects of stimulants developed decades ago.

Cocaine use disorders and suicidal ideation

The goal of this study was to determine the contribution of substance abuse to the expression of suicidal ideation in a sample of patients referred for evaluation of chemical dependency in a large urban Psychiatric Emergency Service (PES). Records from 777 consecutive patients referred to the chemical dependency service of the PES were analyzed. Of this sample, 43.7% of the patients with only a cocaine use disorder expressed suicidal ideation compared to 38% of those with both cocaine and alcohol use disorders, 24.3% with only an alcohol use disorder and 17% with other drug use disorders (chi(2)=24.768; df=3; P<0.0001). More than half of the patients (55.26%) with a substance-induced mood or psychotic disorder expressed suicidal ideation (chi(2)=23.174, df=1, P<0.0001), and the majority (85%) of these patients had a cocaine use disorder (chi(2)=12.309, df=1, P<0.0005). In this sample of patients served by an urban PES, cocaine use is associated with suicidal ideation, more so than other substances of abuse.

Psychiatric and substance use disorders as risk factors for attempted suicide among adolescents: a case control study

The objective of this research was to test substance-related and non-substance-related psychiatric disorders as predictors of attempted suicide among adolescents. Ninety-six psychiatrically disordered suicide attempters were matched one-to-one to 96 psychiatrically disordered non-attempters on age, race, gender, and the presence/absence of major depression. Conditional logistic regression was used to test psychiatric risk factors for their power to predict attempted suicide among adolescents. Bipolar disorder, cocaine use disorders, and conduct disorder were found to be predictive of attempted suicide in univariate testing. Bipolar disorder, inhalant use disorders, cocaine use disorders, and hallucinogen use disorders were found to be predictive of attempted suicide, after adjusting for all other covariates. Loglinear analyses revealed high odds ratios associated with the comorbidities of alcohol use disorder with conduct disorder and drug use disorders with conduct disorder in both groups. Higher rates of cocaine use disorder/conduct disorder, hallucinogen use disorder/conduct disorder, and alcohol use disorder/ conduct disorder were found among suicide attempters. Evaluation of these particular comorbid conditions should be part of the adolescent suicide risk assessment.

Childhood trauma and suicidal behavior in male cocaine dependent patients

A consecutive series of 100 male cocaine dependent patients were interviewed about suicidal behavior and completed the 34-item Childhood Trauma Questionnaire (CTQ) to determine whether childhood trauma is associated with suicidal behavior in cocaine dependent men. Patients who had attempted suicide (n = 34) reported significantly higher scores for childhood emotional abuse, physical abuse, sexual abuse, and emotional and physical neglect than patients who had never attempted suicide (n = 66). In this study, various childhood traumas were found to be significantly associated withsuicidal behavior among adult male cocaine dependent patients.

Serum cholesterol, suicidal behavior and impulsivity in cocaine-dependent patients

Relationships between serum cholesterol and suicidal behavior have been reported. As suicidal behavior is common in cocaine dependence, we looked for a relationship with serum cholesterol. To do this, we compared 57 cocaine-dependent patients who had attempted suicide with 111 cocaine-dependent patients who had never attempted suicide for their admission total serum cholesterol levels. We found that there were no significant differences between cocaine-dependent patients who had or had not attempted suicide in their total serum cholesterol levels. Also, there were no significant correlations between total serum cholesterol levels and scores on the Barratt Impulsivity Scale. Thus, admission total serum cholesterol does not appear to be clinically useful in the assessment of suicidal behavior in cocaine-dependent patients.

Methylphenidate Abuse and Psychiatric Side Effects

Methylphenidate is a central nervous system stimulant drug that has become the primary drug of choice in treating attention-deficit/hyperactivity disorder in children. Side effects are usually mild and are generally well tolerated by patients. Along with increases in prescribing frequency, the potential for abuse has increased. Intranasal abuse produces effects rapidly that are similar to the effects of cocaine in both onset and type. The clinical picture of stimulant abuse produces a wide array of psychiatric symptoms. There is little in the literature to differentiate methylphenidate from other stimulants when they are abused. The need for education of all involved with the use of methylphenidate is discussed to help prevent an increasing pattern of methylphenidate abuse.

An evidence-based approach to evaluating and managing suicidal emergencies

This article presents a framework for making suicide risk estimations, as well as recommendations for the management of suicidal emergencies, that are useful to the practitioner. It provides a review of existing empirical data concerning factors significantly related to acute suicidal behaviors within high-risk diagnoses. Findings across studies are categorized into risk profiles (as proposed by Clark & Fawcett, 1992) that are meant to aid the clinician in the application of recent research. The profiles are intended as templates in development and clearly require continual updating and clarification as new studies are completed. The article then addresses related management issues such as the importance of viewing risk factors within a comprehensive suicide assessment and the impact of possible negative therapist reactions when working with high-risk patients.

Adults mourning suicide: self-reported concerns about bereavement, needs for assistance, and help-seeking behavior

This study empirically characterized the experiences of 227 adult next-of-kin as they mourned suicides that had occurred in New York City during 1997. Next-of-kin reported psychosocial problems including family difficulties, comorbid stressors, psychiatric symptomatology, and unresolved bereavement. Professional intervention was the most frequently reported need and the most frequently reported type of desired help. In terms of actual receipt of assistance, participants reported having received help from families, friends, and communities as well as from professionals. Although some next-of-kin had not sought help because they felt able to cope without assistance, others encounted barriers to receiving desired help. These findings warrant increased and sustained community outreach to this population. Recommendations include public education regarding de-stigmatization of suicide and the needs of the suicidally bereaved, enhancement of internal and external coping supports, facilitation of access to both professional and community help, and better coordinated and more culturally appropriate services.

Sympathomimetic preference and ethnicity in male felons

A disproportionate number of Euro-American inmates given either an amphetamine- or cocaine-abuse diagnosis upon admission to prison were given a diagnosis of amphetamine abuse. A disproportionate number of African-American inmates were given a cocaine-abuse diagnosis. Of the 800 consecutively admitted inmates who were given one diagnosis or the other, 68% of the cocaine abusers, but only 4% of the amphetamine abusers, were African American.

How to spot illicit drug abuse in your patients

Illicit drug abuse continues to become more widespread, especially in teenagers. Therefore, it is important for physicians to recognize the signs and symptoms of abuse in their patients. Drug abuse should be considered in differential diagnosis of many physical and nearly all psychiatric complaints. An understanding of the pharmacologic mechanisms and adverse effects of illicit drugs can enhance overall care of patients who abuse drugs. The primary classes of drugs of abuse--cannabinoids, opiates, stimulants, hallucinogens, and inhalants--produce clinically diverse presentations. By recognizing these unique signs and symptoms, physicians can differentiate between drug-induced conditions any psychiatric illness.