Predictors of suicide attempters in substance-dependent patients: a six-year prospective follow-up

Risk of suicide ideation in comorbid substance use disorder and major depression

BACKGROUND

Suicidal behaviour is commonly associated with major depression (MD) and substance use disorders (SUDs). However, there is a paucity of research on risk for suicide ideation among individuals with comorbid SUDs and MD in the general population.

OBJECTIVES

This study investigated the associated risk of suicide ideation in comorbid SUDs-cannabis use disorder (CUD), alcohol use disorder (AUD), drug use disorder (DUD) with major depressive episode (MDE) in a nationally representative sample.

METHODS

Multilevel logistic regression models were used to analyze the 2012 Canadian Community Health Survey- Mental Health (CCHS-MH) data. This is a cross-sectional survey of nationally representative samples of Canadians (n = 25,113) aged 15 years and older residing in the ten Canadian provinces between January and December 2012. Diagnoses of MDE, AUD, DUD, and CUD were based on a modified WHO-CIDI, derived from DSM-IV diagnostic criteria.

RESULTS

Comorbidity was found to be the strongest predictor of suicide ideation. Compared to those with no diagnosis of either a SUD or MDE, individuals with a comorbid diagnosis of AUD with MDE, CUD with MDE, or DUD with MDE were 9, 11 and 16 times more likely to have 12-month suicide ideation respectively. A diagnosis of MDE was a significant predictor of 12-month suicide ideation with about a 7-fold increased risk compared with individuals not diagnosed with either MDE or a SUD.

CONCLUSION

Suicide is a preventable public health issue. Our study found a significantly increased risk of suicide ideation among persons who have comorbid SUD with MD. Effective integration of mental health and addictions services could mitigate the risk of suicide and contribute to better outcomes.

Effectiveness of a Suicide Prevention Module for Adults in Substance Use Disorder Treatment: A Stepped-Wedge Cluster-Randomized Clinical Trial

IMPORTANCE

Individuals with substance use disorders (SUDs) are at high risk for suicide. The Preventing Addiction Related Suicide (PARS) module is the first suicide prevention module developed in and for community substance use intensive outpatient programs (IOPs).

OBJECTIVE

To evaluate the effectiveness of PARS on suicide-related outcomes (ie, knowledge, attitudes, and help-seeking behavior) compared with usual care.

DESIGN, SETTING, AND PARTICIPANTS

This stepped-wedge cluster-randomized clinical trial was conducted from 2017 to 2020, with follow-up assessments conducted after treatment and at 1, 3, and 6 months. Participants included adult outpatients in SUD treatment at community IOPs across western Washington state. Data were analyzed from July 1, 2020, to January 20, 2022.

INTERVENTIONS

The intervention, PARS, was a 1-session secondary prevention module administered by trained SUD counselors consisting of didactic presentations and group discussions about suicide risk factors, warning signs, and actions to take if suicide risk is observed in self or others. The control group received usual care.

MAIN OUTCOMES AND MEASURES

Primary outcomes were suicide knowledge, attitudes about suicide, and help-seeking behavior among patients enrolled in an IOP.

RESULTS

A total of 906 participants (mean [SD] age, 37.5 [12.0] years; 540 [59.6%] men) were included, with 478 participants receiving usual care and 428 participants receiving PARS. In intent-to-treat analysis from baseline to after treatment, there was a greater improvement in suicide knowledge (d = 0.15; 95% CI, 0.08 to 0.23; P < .001) and a greater reduction in maladaptive attitudes (d = 0.18; 95% CI, 0.14 to 0.25; P < .001) for PARS participants compared with those receiving usual care. Improvements were maintained at follow-up for suicide knowledge (1 month: d = 0.16; 95% CI, 0.07 to 0.22; P < .001; 3 months: d = 0.12; 95% CI, 0.05 to 0.19; P = .001; 6 months: d = 0.13; 95% CI, 0.06 to 0.20; P < .001) and reductions in maladaptive attitudes (1 month: d = 0.20; 95% CI, 0.12 to 0.23; P < .001; 3 months: d = 0.10; 95% CI, 0.05 to 0.16; P < .001; 6 months: d = 0.14; 95% CI, 0.09 to 0.19; P < .001), with 788 participants (87.0%) of the sample responding across time points. From baseline to 6 months, there was a greater improvement in help-seeking in the PARS group vs usual care (d = 0.16; 95% CI, 0.01 to 0.32; P = .04).

CONCLUSIONS AND RELEVANCE

This stepped-wedge cluster-randomized clinical trial found that PARS was superior to usual care in improving suicide knowledge, maladaptive attitudes, and help-seeking in adults undergoing community addiction treatment. As a 1-session IOP module developed in partnership with community addiction agencies, PARS has the potential for wide impact in the national suicide prevention strategy.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03166709.

Suicidal behavior in problematic substance uses in South Gondar zone, Northwest Ethiopia: a cross-sectional survey

Background

Suicidal behavior has a significant contribution to the global burden of disease that affects individuals, families and communities at different age groups. Sadly, up to 75% of suicides in the world occur in low-and- middle income countries which have no adequate resource to prevent it. The aim of this study was to assess suicidal behavior and associated factors among community residents with problematic substance use in South Gondar zone, northwest Ethiopia.

Methods

Community based cross-sectional survey was conducted by using a suicidal behavior revised questionnaire from January 15 to March 15, 2019. A total of 4035 participants were screened for problematic substance use by using multi stage cluster sampling and 846 participants were positive for problematic substance use then asked for suicidal behavior. Multiple logistic regression analyses used to see adjusted odd rations (AOR). Multilevel binary logistic regression was used to account for the hierarchical structure of the two-level data within individual and districts level.

Results

The prevalence of suicidal behavior over the last 12 months in problematic substance uses was found to be 41.4% with 95% of confidence interval (CI) (38.2–44.9). Perceived stigma, [AOR = 1.605, 95% CI (1.16–2.23)], family history of suicide [AOR = 3.22, 95% CI (1.46–7.10)], physical illness [AOR = 2.45 95% CI (1.157–3.84)], rural resident [AOR = 1.74, 95% CI (1.16–2.62)], depression [AOR = 4.44, 95% CI (3.15–6.27)] and living alone (AOR = 1.61, 95% CI (1.16–2.24) were risks factors for suicidal behavior.

Conclusion

Suicidal behavior in problematic substance uses found to be high. Health workers should pay attention to decrease suicidal behavior and to control amendable factors.

Profiles of Risk for Suicidal Behavior in Past and Current United States Military Personnel: Latent Profile Analysis of Current Risk Factors

Person-centered approaches are underutilized to identify people with shared risk profiles. In this study, an at-risk sample of 773 past/current military personnel (Mage = 31.3 years, SD = 6.8) with current ideation (90.6%) and/or a prior suicide attempt (43.9%) were assessed using latent profile analysis. Variables included prior suicide attempts, suicidal ideation, alcohol/drug use, insomnia, depression, belongingness, burdensomeness, and post-traumatic stress disorder symptoms. Three classes emerged: Low Symptoms (N = 502), Elevated Suicidality (N = 176), and Elevated Substance Use (N = 95). At 1-month follow-up, the Elevated Suicidality and Elevated Substance Use classes had the highest odds of suicidal behavior. The finding concerning the Elevated Substance Use class suggests it may represent a distinct short-term risk group in military personnel.

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

BACKGROUND

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

METHODS

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

DISCUSSION

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

SYSTEMATIC REVIEW REGISTRATION

PROSPERO (reference number: CRD42018076260).

Suicidal ideation and attempts in patients who seek treatment for substance use disorder

Patients with substance dependence have a great risk of suicidal ideation and attempts. The study of the specific risk characteristics of patients with substance use disorders who present with suicidal ideation and/or attempts becomes a crucial clinical issue in order to develop prevention strategies. The main goals of this study were to determine the prevalence rate of both suicidal ideation and attempts among patients receiving treatment for substance use disorder and to analyse the differential characteristics between these patients with and without suicidal behaviours. A sample of 334 patients (263 men-71 women) who sought treatment for substance use disorder in a Spanish clinical centre was assessed. In total, 43.7% of the patients presented with lifetime suicidal ideation (8.7% in the last month) and 17.7% with suicide attempts (1.5% in the last month). Patients with suicidal ideation or attempts showed a more severe addiction profile (assessed by the EuropASI), and more psychopathological symptoms (assessed by the SCL-90-R). Moreover the rate of suicidal ideation and attempts was significantly higher in inpatients than in outpatients. According to these results, systematic screening of suicidal risk in patients seeking treatment for substance use disorders is recommended, especially in those with a greater addiction severity.

Associations among Substance Use, Mental Health Disorders, and Self-Harm in a Prison Population: Examining Group Risk for Suicide Attempt

Substance use disorders (SUD) and mental health disorders are significant public health issues that co-occur and are associated with high risk for suicide attempts. SUD and mental health disorders are more prevalent among offenders (i.e., prisoners or inmates) than the non-imprisoned population, raising concerns about the risk of self-harm. This cross-sectional study examined the population of a state prison system (10,988 out of 13,079) to identify associations among SUD (alcohol, cannabis, intravenous drugs, narcotics, and tobacco smoking), mental health disorders (anxiety, bipolar, depression, and psychotic disorders), and suicide attempts. The primary aim was to determine which groups (SUD, mental health disorders, and co-occurrences) were strongly association with suicide attempts. Groups with a documented SUD or mental health disorders compared to peers without these issues had 2.0 and 9.2 greater odds, respectively, for attempting suicide, which was significant at p < 0.0001 for both conditions. There were also significant differences within SUD and mental health disorders groups in regard to suicide attempts. Groups with the greatest odds for suicide attempts were offenders with comorbid bipolar comorbid and anxiety, alcohol combined with depression, and cannabis co-occurring with depression. Documentation of suicide attempts during imprisonment indicates awareness, but also suggest a need to continue enhancing screening and evaluating environmental settings.

Prediction of Suicide Ideation and Attempt Among Substance-Using Patients in Primary Care

BACKGROUND

Suicide is a major public health concern, particularly among people who use illicit substances and/or non-prescribed medications.

METHODS

The present study prospectively assessed the incidence and predictors of suicidal ideation (SI) and suicide attempt (SA) among 868 substance-using patients over 12 months after receiving primary care within seven public primary care clinics.

RESULTS

Participants reported a high incidence of SI (25.9%) and SA (7.1%) over the year following primary care visits. Suicidality was elevated in patients who were female; lacked a high school diploma; were unemployed; reported depression, anxiety, hallucinations, concentration difficulty, or violent behavior; used nicotine or stimulants; used the emergency department or mental health services in the past 90 days; reported current quality-of-life impairment in mobility or usual activities; or reported recent SI or lifetime SA at baseline. In multiple regression analyses, only past 30-day SI, any lifetime SA, past 90-day violent behavior, and current impairment due to anxiety or depression at baseline uniquely predicted SI or SA beyond other variables.

CONCLUSIONS

Results support the need for screening for suicidality among primary care patients who use illicit substances and identify key of these patients who are at particularly elevated risk for suicidality.

International Adaptations of the Millon Clinical Multiaxial Inventory: Construct Validity and Clinical Applications

This article examines the influence of the Millon Clinical Multiaxial Inventory (MCMI) as a clinical and research instrument beyond the borders of the United States. The MCMI's theoretical and empirical grounding, its alignment with the Diagnostic and Statistical Manual of Mental Disorders (DSM), and scales that can be interpreted both categorically and dimensionally, are the primary features that make the test attractive. We begin with studies that evaluated the construct equivalence of the different language adaptations. Data from the most widely researched non English-language forms (Danish, Dutch, and Spanish) show excellent comparability with Millon's original. Nevertheless, significant problems were noted in efforts to create clinical groups that would allow for equivalence of diagnostic accuracy when using the cutoff scores. Although dimensional aspects of the scale scores were not affected by this, the adapted measures might show attenuated diagnostic accuracy compared with Millon's original. Next, we present MCMI studies conducted in clinical settings to document where the adapted tests have made their greatest impact in the international literature. A wide variety of clinical applications demonstrated broad utility, and given the high number of issues addressed, we think Millon's influence will certainly stand the test of time in different domains and settings.

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

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

Anxiety and its disorders as risk factors for suicidal thoughts and behaviors: A meta-analytic review

Suicidal thoughts and behaviors are highly prevalent public health problems with devastating consequences. There is an urgent need to improve our understanding of risk factors for suicide to identify effective intervention targets. The aim of this meta-analysis was to examine the magnitude and clinical utility of anxiety and its disorders as risk factors for suicide ideation, attempts, and deaths. We conducted a literature search through December 2014; of the 65 articles meeting our inclusion criteria, we extracted 180 cases in which an anxiety-specific variable was used to longitudinally predict a suicide-related outcome. Results indicated that anxiety is a statistically significant, yet weak, predictor of suicide ideation (OR=1.49, 95% CI: 1.18, 1.88) and attempts (OR=1.64, 95% CI: 1.47, 1.83), but not deaths (OR=1.01, 95% CI: 0.87, 1.18). The strongest associations were observed for PTSD. Estimates were reduced after accounting for publication bias, and diagnostic accuracy analyses indicated acceptable specificity but poor sensitivity. Overall, the extant literature suggests that anxiety and its disorders, at least when these constructs are measured in isolation and as trait-like constructs, are relatively weak predictors of suicidal thoughts and behaviors over long follow-up periods. Implications for future research priorities are discussed.

Suicidal ideation and lifetime attempts in substance and gambling disorders

Suicidality is more commonly reported among individuals with addictions relative to the general population, though data from Asian countries remain scarce. The medical records of 2187 Singaporean patients with drug (n=879), alcohol (n=754) or gambling (n=554) disorders entering an outpatient treatment service were examined to explore differences in suicidal ideation and lifetime attempts between substance and gambling addictions. The relationship between suicidality, co-morbidity and addiction severity were also examined. 25.0% reported thoughts of suicide in the past month, 11.8% had a suicide plan and 12.2% reported lifetime attempts. Rates of suicidal ideation (thoughts, and plan) but not lifetime attempts were significantly higher among gambling than substance use patients. Co-morbid (DSM-IV axis-1) disorders were found among 32.5%, 38% and 40% of those reporting thoughts, plan and lifetime attempts respectively. Addiction severity was higher and quality of life lower among those reporting suicidal behaviors. Logistic regression revealed co-morbidity, debt, gender (being female) and being a gambling patient as significant predictors of suicidal behaviors. The findings highlight the importance of screening for suicidality, even in the absence of co-morbidity, particularly among gambling disorder patients with debts. Suicide risk should be assessed periodically and referral to suicidal prevention interventions routinely offered to this vulnerable population.

Psychometric properties of the Turkish versions of the Drug Use Disorders Identification Test (DUDIT) and the Drug Abuse Screening Test (DAST-10) in the prison setting

The aim of this study was to evaluate psychometric properties of the Drug Use Disorders Identification Test (DUDIT) and the Drug Abuse Screening Test (DAST-10) in prisoners with (n = 124) or without (n = 78) drug use disorder. Participants were evaluated with the DUDIT, the DAST-10, and the Addiction Profile Index-Short (API-S). The DUDIT and the DAST-10 were found to be psychometrically sound drug abuse screening measures with high convergent validity when compared with each other (r = 0.86), and API-S (r = 0.88 and r = 0.84, respectively), and to have a Cronbach's α of 0.93 and 0.87, respectively. In addition, a single component accounted for 58.28% of total variance for DUDIT, whereas this was 47.10% for DAST-10. The DUDIT had sensitivity and specificity scores of 0.95 and 0.79, respectively, when using the optimal cut-off score of 10, whereas these scores were 0.88 and 0.74 for the DAST-10 when using the optimal cut-off score of 4. Additionally, both the DUDIT and the DAST-10 showed good discriminant validity as they differentiated prisoners with drug use disorder from those without. Findings support the Turkish versions of both the DUDIT and the DAST-10 as reliable and valid drug abuse screening instruments that measure unidimensional constructs.

Convergent validity of the ASAM criteria in co-occurring disorders

OBJECTIVE

The complexity of substance use and psychiatric disorders demands thorough assessment of patients for integrated services. We tested the convergent validity of the software version of the American Society of Addiction Medicine (ASAM) second edition-revised criteria for patient placement by examining the software's ability to discriminate based on a variety of demographic and clinical factors.

METHODS

This prospective naturalistic multi-site study examined the software's assignment of patients to three types of treatment (addiction only services, dual diagnosis capable, and dual diagnosis enhanced) and whether these assignments indicated an ability to discriminate between patients with and without dual diagnosis based on clinical characteristics and severity. Ten addiction treatment clinics spanning three counties participated, and both patients and ASAM assessors were kept blind to the ASAM recommendation. Patients were assigned to their respective treatment options based on routine assessment by clinicians at intake, which they had in addition to the ASAM interview. Three months after treatment initiation a follow-up interview with ASAM was conducted.

RESULTS

There were 261 patients in the study, 96 (36.7%) were assigned to addiction only services, 42 (16.1%) to dual diagnosis capable, and 123 (47.1%) to dual diagnosis enhanced. Patients assigned to the two dual diagnosis groups were significantly more likely to be younger and have fewer years of work than other patients. There were significant differences in history of inpatient and outpatient psychiatric treatment across groups. For example, a larger percentage of those in addiction only services had never been in inpatient treatment, while more of those in the two dual diagnosis groups had three or more inpatient stays. Despite similar alcohol and drug severity scores, patients recommended by the software for dual diagnosis enhanced programs showed a gradient of significantly higher psychiatric (p <.001), legal (p <.04), and family (p <.001) Addiction Severity Index composite scores at baseline than patients in dual diagnosis capable and addiction only services.

CONCLUSIONS

RESULTS show a high prevalence of co-occurring program recommendations with statistically significant and clinically meaningful differences between patient groups. The convergent validity of the revised version of ASAM Criteria Software is supported by these results.

Deliberate self-harm in nondepressed substance-dependent patients

OBJECTIVE

The lifetime diagnosis of substance dependence syndrome is a major risk factor for attempting suicide. The systematic study of various risk factors of suicide in substance-dependent patients in Indian population will have far-reaching implications about the understanding of disorder. The objective was to study the sociodemographic and clinical factors associated with deliberate self-harm (DSH) in nondepressed substance-dependent patients.

METHODS

Participants included 60 male inpatients (30 patients with DSH and 30 without DSH) fulfilling International Classification of Diseases, Tenth Revision Diagnostic Criteria for Research for substance dependence syndrome, aged between 18 and 60 years, with Hamilton Depression Rating Scale score fewer than 7. They were assessed using Addiction Severity Index, Presumptive Stressful Life Event Scale, State-Trait Anger Expression Inventory, Lubben Social Network Scale, International Personality Disorder Examination, Risk Rescue Rating Scale, and Global Assessment of Functioning.

RESULT

Patients with DSH had significantly higher rates of opioid dependence (P < .05), risk of isolation (P < 0.001), the number of life events (P < 0.001), anger trait and anger expression (P < 0.001), personality disorder (P < 0.05), the number of substance use problems and lower social functioning (P < 0.001), as compared with those without DSH (P < 0.001). There was no significant correlation between Risk Rescue Rating Scale with sociodemographic and clinical variables.

CONCLUSIONS

The study demonstrated that patients with opioid dependence, high risk of isolation, the greater number of life events, higher anger trait and anger expression, personality disorder, low social functioning, and greater number of substance use problems have risk for DSH.

Psychometric properties of the Drug Use Disorders Identification Test (DUDIT) with substance abusers in outpatient and residential treatment

The psychometric properties of the Drug Use Disorders Identification Test (DUDIT), an 11-item self-report questionnaire developed to screen individuals for drug problems, are evaluated. The measure, developed in Sweden and evaluated there with individuals with severe drug problems, has not been evaluated with less severe substance abusers or with clinical populations in the United States. Participants included 35 drug abusers in an outpatient substance abuse treatment program, 79 drug abusers in a residential substance abuse treatment program, and 39 alcohol abusers from both treatment settings who did not report a drug abuse problem. The DUDIT was found to be a psychometrically sound drug abuse screening measure with high convergent validity (r=.85) when compared with the Drug Abuse Screening Test (DAST-10), and to have a Cronbach's alpha of .94. In addition, a single component accounted for 64.91% of total variance, and the DUDIT had sensitivity and specificity scores of .90 and .85, respectively, when using the optimal cut-off score of 8. Additionally, the DUDIT showed good discriminant validity as it significantly differentiated drug from alcohol abusers. These findings support the DUDIT as a reliable and valid drug abuse screening instrument that measures a unidimensional construct. Further research is warranted with additional clinical populations.

The influence of the comorbidity between depression and alcohol use disorder on suicidal behaviors in the São Paulo Epidemiologic Catchment Area Study, Brazil

OBJECTIVE

To investigate in a community sample the association of suicide-related cognitions and behaviors ("thoughts of death", "desire for death", "suicidal thoughts", and "suicidal attempts") with the comorbidity of depressive disorders (major depressive episode or dysthymia) and alcohol or substance use disorders.

METHOD

The sample was 1464 subjects interviewed in their homes using the Composite International Diagnostic Interview to generate DSM-III-R diagnosis. Descriptive statistics depicted the prevalence of suicide-related cognitions and behaviors by socio-demographic variables and diagnoses considered (major depressive episode, dysthymia, alcohol or substance use disorders). We performed a multivariate logistic regression analysis to estimate the effect of comorbid major depressive episode/dysthymia and alcohol or substance use disorders on each of the suicide-related cognitions and behaviors.

RESULTS

The presence of major depressive episode and dysthymia was significantly associated with suicide-related cognitions and behaviors. In the regression models, suicide-related cognitions and behaviors were predicted by major depressive episode (OR=range 2.3-9.2) and dysthymia (OR=range 5.1-32.6), even in the presence of alcohol use disorders (OR=range 2.3-4.0) or alcohol or substance use disorders (OR=range 2.7-2.8). The interaction effect was observed between major depressive episode and alcohol use disorders, as well as between dysthymia and gender. Substance use disorders were excluded from most of the models.

CONCLUSION

Presence of major depressive episode and dysthymia influences suicide-related cognitions and behaviors, independently of the presence of alcohol or substance use disorders. However, alcohol use disorders and gender interact with depressive disorders, displaying a differential effect on suicide-related cognitions and behaviors.

Deaths of opiate/opioid misusers involving dihydrocodeine, UK, 1997-2007

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT

Dihydrocodeine (DHC) is an opioid analgesic sometimes prescribed as an alternative to other medications (e.g. methadone and buprenorphine) for opioid misuse. Its effectiveness is, however, still controversial. DHC prescription rates seem to be related to levels of DHC fatalities, possibly in relation to levels of disregard of the availability of supervised or interval dispensing of opioids, but no large-scale analysis of DHC fatalities has been carried out. We analysed here involvement of DHC in fatalities that occurred between 1997 and 2007 among individuals with a history of opiate/opioid misuse reported to the National Programme on Substance Abuse Deaths (np-SAD).

WHAT THIS STUDY ADDS

DHC, either alone or in combination, was identified in 584 fatalities. Typical cases identified were males in their early thirties. In accidental overdoses, DHC, which had been prescribed to 45% of the victims, was typically identified in combination with other drugs, such as heroin/morphine, methadone and hypnotics/sedatives. Both paracetamol and antidepressants were more typically identified in combination with DHC in suicides. Opiate/opioid misusers should be educated about risks associated with polydrug intake and prescribers should carefully consider a pharmacological intervention alternative to DHC (e.g. methadone, buprenorphine) when managing and treating opiate addiction.

AIMS

Although its effectiveness is somewhat controversial, it appears that dihydrocodeine (DHC) is still prescribed in the UK as an alternative to both methadone and buprenorphine for the treatment of opiate addiction.

METHODS

Data covering the period 1997-2007 voluntarily supplied by coroners were analysed. All cases pertaining to victims with a clear history of opiate/opioid misuse and in which DHC, either on its own or in combination, was identified at post-mortem toxicology and/or implicated in death, were extracted from the database.

RESULTS

Dihydrocodeine, either alone or in combination, was identified in 584 fatalities meeting the selection criteria. In 44% of cases it was directly implicated in the cause of death. These cases represented about 6.8% of all opiate/opioid-related deaths during this period. Typical DHC cases identified were White males in their early thirties. Accidental deaths (96%) were likely to involve DHC in combination with other psychoactives, mainly heroin/morphine, hypnotics/sedatives and methadone. Both paracetamol and antidepressants were found in proportionately more suicide cases than in accidental overdoses. DHC had been prescribed to the decedent in at least 45% of cases.

CONCLUSIONS

Opiate/opioid misusers should be educated about risks associated with polydrug intake. More in particular, co-administration of DHC with heroin, methadone and benzodiazepines may increase the risk of accidental fatal overdose. Prescribers should carefully consider pharmacological intervention alternative to DHC (e.g. methadone, buprenorphine) when managing and treating opiate addiction. More resources are required to do prospective research in this area.

Suicide attempts within 12 months of treatment for substance use disorders

There are limited prospective data on suicide attempts (SA) during the months following treatment for substance use disorders (SUD), a period of high risk. In an analysis of the Drug Abuse Treatment Outcomes Study, a longitudinal naturalistic multisite study of treated SUDs, variables associated with SA in the 12 months following SUD treatment were examined. Participants included 2,966 patients with one or more SUDs. By 12 months, 77 (2.6%) subjects had attempted suicide. Multivariate logistic regression analyses were used to identify variables associated with SA. Variables collected at baseline that were associated with SA included lifetime histories of SA, suicidal ideation (SI), depression, cocaine as primary substance of use, outpatient methadone treatment, and short-term inpatient treatment. Male sex, older age, and minority race or ethnicity were associated with lower likelihood of SA. After controlling for baseline predictors, variables assessed at 12 months associated with SA included SI during follow-up and daily or more use of cocaine. The data contribute to a small but growing literature of prospective studies of SA among treated SUDs, and suggest that SUDs with cocaine use disorders in particular should be a focus of prevention efforts.

Factors Associated with the History of Attempted Suicide

Background: The present study examines a population of criminal justice clients for suspected substance-related problems. Aims: It aims to identify variables associated with a history of suicide attempt (SA). Method: 6,836 clients were interviewed with the Addiction Severity Index (ASI). Attempters were compared to nonattempters regarding substance use, medical/psychiatric status, family history, and social relationships in a stepwise forward logistic regression. Results: Attempters (21%) were more likely to report binge drinking, intake of illicit drugs, injection of drugs, physical and mental illness, problematic family history, and history of being abused. After logistic regression, SA was independently associated with older age, female gender, binge drinking, delirium tremens, injection, overdose, medical problems, psychiatric symptoms, family history of alcohol or psychiatric problems, and sexual, physical, and emotional abuse. The psychiatric and family/social domains (including being abused) most strongly separated attempters from nonattempters. Conclusions: Family background factors, psychiatric symptoms, severity of substance use, and sexual, physical, and emotional abuse appear to be factors associated with SA among criminal justice clients.