Attempted suicide, self-harm, and violent victimization among regular illicit drug users

Improving assessment and management of suicide risk among people who inject drugs: A mixed methods study conducted at the Medically Supervised Injecting Centre, Sydney

INTRODUCTION

People who inject drugs are 13 times more likely to die by suicide than the general population. Guidelines for responding to risk in this population are limited. Harm reduction services attended by people who inject drugs require targeted strategies to address the complexities of suicide risk among this population.

METHODS

Co-design, engaging health professionals and people with lived experience informed the study. Mixed methods were used to understand the experience of managing suicide risk among clients attending the Medically Supervised Injecting Centre (MSIC) in Sydney. A survey was administered to assess staff confidence in managing risk. Focus groups were conducted with health professionals and MSIC clients to explore experiences of suicide management, response and opportunities for improvement.

RESULTS

Half (N = 17) the MSIC staff surveyed reported over 10 years' experience working with this population. Confidence in managing suicide risk was low. Three key themes emerged from focus groups (N = 17): (i) Autonomy and the need to involve clients in the assessment process; (ii) Trust between clients and health professionals, and transparency in decision-making; and (iii) System barriers, described by health professionals as inadequate referral pathways for clients in distress, and by clients as negative experiences of care, including involuntary admission and not receiving medication (e.g. methadone).

DISCUSSION AND CONCLUSIONS

Revised assessment guidelines and a tailored safety plan were developed. These resources are also suitable for other alcohol and other drug services. The challenge in managing suicide risk in harm reduction services is balancing duty of care with staff-client relationships and client engagement.

Predicting suicide attempts among Norwegian adolescents without using suicide-related items: a machine learning approach

Introduction

Research on the classification models of suicide attempts has predominantly depended on the collection of sensitive data related to suicide. Gathering this type of information at the population level can be challenging, especially when it pertains to adolescents. We addressed two main objectives: (1) the feasibility of classifying adolescents at high risk of attempting suicide without relying on specific suicide-related survey items such as history of suicide attempts, suicide plan, or suicide ideation, and (2) identifying the most important predictors of suicide attempts among adolescents.

Methods

Nationwide survey data from 173,664 Norwegian adolescents (ages 13-18) were utilized to train a binary classification model, using 169 questionnaire items. The Extreme Gradient Boosting (XGBoost) algorithm was fine-tuned to classify adolescent suicide attempts, and the most important predictors were identified.

Results

XGBoost achieved a sensitivity of 77% with a specificity of 90%, and an AUC of 92.1% and an AUPRC of 47.1%. A coherent set of predictors in the domains of internalizing problems, substance use, interpersonal relationships, and victimization were pinpointed as the most important items related to recent suicide attempts.

Conclusion

This study underscores the potential of machine learning for screening adolescent suicide attempts on a population scale without requiring sensitive suicide-related survey items. Future research investigating the etiology of suicidal behavior may direct particular attention to internalizing problems, interpersonal relationships, victimization, and substance use.

Are false positives in suicide classification models a risk group? Evidence for "true alarms" in a population-representative longitudinal study of Norwegian adolescents

Introduction

False positives in retrospective binary suicide attempt classification models are commonly attributed to sheer classification error. However, when machine learning suicide attempt classification models are trained with a multitude of psycho-socio-environmental factors and achieve high accuracy in suicide risk assessment, false positives may turn out to be at high risk of developing suicidal behavior or attempting suicide in the future. Thus, they may be better viewed as "true alarms," relevant for a suicide prevention program. In this study, using large population-based longitudinal dataset, we examine three hypotheses: (1) false positives, compared to the true negatives, are at higher risk of suicide attempt in future, (2) the suicide attempts risk for the false positives increase as a function of increase in specificity threshold; and (3) as specificity increases, the severity of risk factors between false positives and true positives becomes more similar.

Methods

Utilizing the Gradient Boosting algorithm, we used a sample of 11,369 Norwegian adolescents, assessed at two timepoints (1992 and 1994), to classify suicide attempters at the first time point. We then assessed the relative risk of suicide attempt at the second time point for false positives in comparison to true negatives, and in relation to the level of specificity.

Results

We found that false positives were at significantly higher risk of attempting suicide compared to true negatives. When selecting a higher classification risk threshold by gradually increasing the specificity cutoff from 60% to 97.5%, the relative suicide attempt risk of the false positive group increased, ranging from minimum of 2.96 to 7.22 times. As the risk threshold increased, the severity of various mental health indicators became significantly more comparable between false positives and true positives.

Conclusion

We argue that the performance evaluation of machine learning suicide classification models should take the clinical relevance into account, rather than focusing solely on classification error metrics. As shown here, the so-called false positives represent a truly at-risk group that should be included in suicide prevention programs. Hence, these findings should be taken into consideration when interpreting machine learning suicide classification models as well as planning future suicide prevention interventions for adolescents.

Emergency department use for mental and substance use disorders: descriptive analysis of population-based, linked administrative data in British Columbia, Canada

OBJECTIVES

Information on emergency department (ED) visits for mental and substance use disorders (MSUDs) is important for planning services but has not been explored in British Columbia (BC), Canada. We describe all MSUD ED visits for people ages 15 and older in the province of BC in 2017/2018 and document trends in MSUD ED visits between 2007/2008 and 2017/2018 by disorder group.

DESIGN

Population-based linked administrative data comprised of ED records and physician billings capturing all MSUD ED visits in BC.

SETTING

BC is Canada's westernmost province with a population of approximately 5 million. Permanent residents receive first-dollar coverage for all medically necessary services provided by licensed physicians or in hospitals, including ED services.

POPULATION

All people age >15 with MSUD ED visits during the study period.

MEASURES

All claims with a service location in the ED or corresponding to fee items billed only in the ED were examined alongside ED visits reported through a national reporting system. Patient characteristics (sex/gender, age, location of residence, income, treated disorders and comorbidities) and previous outpatient service use for all ED visits by visit diagnosis are also described.

RESULTS

A total of 72 363 people made 134 063 visits to the ED in 2017/2018 for needs related to MSUD. MSUD ED visits have increased since 2010, particularly visits for substance use and anxiety disorders. People with more frequent visits were more likely to be male, on public prescription drug plans for income assistance, prescribed psychiatric medications, and living in lower-income neighbourhoods. They used more community-based primary care and psychiatry services and had lower continuity of primary care.

CONCLUSIONS

MSUD ED visits are substantial and growing in BC. Findings underscore a need to strengthen and target community healthcare services and adequately resource and support EDs to manage growing patient populations.

Substance use and suicide outcomes among self-injured trauma patients

BACKGROUND

Research indicates alcohol (AUD) or substance (SUD) use disorders and acute alcohol or drug use serve as risk factors for suicidal behaviors and death both distally and proximally to a suicidal event. However, limited research has investigated these relationships among medically serious suicide attempters at the time of injury without relying on cohorts of substance users only or by examining suicide decedent characteristics.

METHODS

Data were collected from the National Trauma Data Bank (NTDB) for 2017. The sample comprised patients who engaged in suicidal and self-injurious acts that were medically serious enough to require trauma admission and were tested for alcohol (N = 9,196) or drug (N = 8,121) exposure upon admission. Logistic regression determined relationships between acute alcohol/substance use, presence of AUDs and SUDs and suicide mortality risk, while linear regression evaluated substance conditions and injury severity and length of stay (LOS).

RESULTS

AUDs (OR = 0.59[0.42-0.83]) and SUDs (OR = 0.66[0.48-0.90]) had reduced odds of death but increased LOS (β = 1.7, p < .001; β = 0.82, p = .024). Blood alcohol concentration (BAC) was positively associated with reduced odds of death (OR = 0.20[0.06-0.61]), injury severity (β = -5.3, p < .001), and LOS (β = -7.5, p < .001). Presence of cocaine (β = -0.80, p = .044) and opioids (β = -1.4, p < .001) were associated lower injury severity, while MDMA (β = 3.6, p = .016) and methamphetamine (β = 1.5, p = .025) were associated with increased injury severity.

CONCLUSIONS

While higher BAC may be associated with lower odds of mortality during a single high-risk suicide event, substance users may be at increased risk for worse outcomes over time. Targeted interventions should be considered to interrupt and develop healthy alternatives for survivors with substance use conditions.

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

Purpose of Review

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

Recent Findings

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

Summary

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

Non-Suicidal Self-Injury Among Incarcerated Adolescents: Prevalence, Personality, and Psychiatric Comorbidity

Introduction: Incarcerated adolescents represent a risk group for non-suicidal self-injury (NSSI), but research on this population has been limited and no studies have been conducted in Russia. To address this deficit, this study examined NSSI and the factors associated with it among youth in a juvenile correctional facility in Russia. Methods: NSSI and psychopathology were assessed using a psychiatric interview and self-report questionnaire in 368 incarcerated male adolescents aged 14-19 years (mean age 16.4 years, S.D. 0.9) from Northern Russia. Results: 18.2% (N = 67) of the study participants had a history of NSSI and also had higher rates of anxiety, post-traumatic stress disorder (PTSD), depression, community violence exposure and scored higher on most of the Youth Self-Report problem scales. In addition, 31.3% of the NSSI group reported previous suicidal ideation and had thought about a specific suicide method compared to 12.0% in the No-NSSI group. Adolescents with NSSI also differed significantly from the No-NSSI group on self-directedness (lower) and self-transcendence (higher) personality traits. Conclusion: NSSI is common in incarcerated adolescents in Russia and is associated with extensive psychiatric comorbidity, suicidal ideation and specific personality traits.

Suicide Attempts and Perceived Social Support among Chinese Drug Users: The Mediating Role of Self-Esteem and Depression

Suicidal behavior is a severe problem among drug users. This study examines influential factors related to suicide attempts and analyzes possible mediators of the relationship between perceived social support and suicide attempts amongst Chinese drug users under compulsory institutional drug treatment. Taking perceived social support as the independent variable, we found that the relationship between suicide attempts and perceived social support is mediated by self-esteem as a protective factor and depression as a risk factor. Path analysis shows that self-esteem contributes relatively more to the indirect effects than depression does, accounting for 31.1% and 24.2% of the total effect, respectively. Generally speaking, the findings of this study point to an urgent need for addressing suicide attempts among Chinese drug users while treating self-esteem as the protective factor that deserves as substantial attention as depression receives.

Suicide attempts and death among heroin-involved women seeking methadone treatment in Taiwan

BACKGROUND

The present study aims to profile the hazard fluctuation of suicide attempts and deaths among heroin-involved women seeking methadone maintenance treatment (MMT) and to investigate sociodemographic and clinical factors predicting the time to have suicidal behaviors.

METHODS

We identified a retrospective cohort comprising 2780 women receiving methadone treatment in the period of 2012-2016. Healthcare records were obtained from Taiwan's National Health Insurance Research Database, and suicide deaths were ascertained from the national death register. Competing risk survival analyses were used to estimate the risk of suicide attempts and deaths within one year and three years of MMT enrollment.

RESULTS

A total of 1.2 % of MMT-treated women ever visited hospital for suicide attempt, and 0.5 % died by confirmed suicide. The risk of treated suicide attempt reached its peak at the end of the 8th month after methadone initiation, whereas the risk of confirmed suicide death was relatively stable during the first one and a half years. A history of treated depressive disorders appears to be the strongest risk predictor for treated suicide attempts (Adjusted Hazard Ratio [aHR] = 3.45; 95 % CI = 1.66-7.19) and confirmed suicide death (aHR = 3.47; 95 % CI = 1.20-10.0). Retaining in methadone treatment may significantly lower the hazard of probable suicide death by 52 %.

CONCLUSIONS

Women with heroin use disorders should receive careful attention for suicide risk at intake assessment and over the course of treatment and recovery. Preventive strategies should target unmet clinical and social needs and evaluate gender-specific barriers for treatment engagement.

Direct and indirect associations between perception of childhood trauma and suicidal ideation through emotion dysregulation in males who use heroin

Emotion dysregulation is considered as one of the factors related to suicide in individuals with childhood trauma (CT). However, no research has been performed on the role of emotion dysregulation in the relationship between perception of CT and suicidal ideation in individuals who use heroin. This study aimed to evaluate direct and indirect relationships between perception of CT and suicidal ideation through emotion regulation difficulties (ERD) and cognitive emotion regulation strategies (CERSs) in males with a DSM diagnosis of heroin dependence. In a cross-sectional design, 310 males with a DSM diagnosis of heroin dependence completed the Childhood Trauma Questionnaire-Short Form (CTQ-SF), the Difficulties in Emotion Regulation Scale (DERS), the Cognitive Emotion Regulation Questionnaire-Short version (CERQ-Short), the Obsessive-Compulsive Drug Use Scale-Form Heroin (OCDUS-Form Heroin), and the Depression Anxiety Stress Scales (DASS). The results revealed that perception of CT had no direct relation to suicidal ideation. Perception of CT was indirectly associated with suicidal ideation through some ERD dimensions [e.g., non-acceptance of emotional responses (Non-acceptance), limited access to emotion regulation strategies (Strategies), lack of emotional awareness (Awareness)] and the CERS of positive reappraisal. The findings suggest that high suicidal ideation may stem from a perception of CT and subsequently emotion dysregulation in individuals who use heroin. Also, the findings of this research may have implications for the prevention and treatment of suicidal ideation in individuals using heroin with a perception of CT. The results of the present study require further examination through longitudinal studies.

Predicting status along the continuum of suicidal thoughts and behavior among those with a history of nonsuicidal self-injury

Nonsuicidal self-injury (NSSI) and suicidal thoughts and behavior often co-occur, representing a growing public health concern. Despite extensive research examining suicidal thoughts and behavior among those who engage in NSSI, there is a lack of research investigating factors that, when considered together, can differentiate individuals along the continuum of suicidal thoughts and behavior (no history, suicidal ideation, suicide plan, suicide attempt). This study sought to address this question using a sample of 1178 college students with NSSI history (68.70% female). Discriminant function analysis was conducted including the following predictors: NSSI characteristics, negative affect difficulties, and behavioral and demographic risk factors for suicidal thoughts and behavior. Results suggest that self-disclosure of suicidal ideation, number of lifetime NSSI methods, NSSI frequency, depressive symptoms, and age most parsimoniously differentiate study groups. Those who use a greater number of NSSI methods and acts, paired with higher depressive symptoms and repeated self-disclosure of suicidal ideation are most likely to have a suicide attempt history; decreases in these variables suggest membership within less severe groups. Furthermore, older age may be related to greater suicidality. Findings suggest that the evaluation and co-occurrence of these variables may contribute to a more accurate suicide risk assessment.

Common genetic contributions to high-risk trauma exposure and self-injurious thoughts and behaviors

BACKGROUND

Prior research has documented shared heritable contributions to non-suicidal self-injury (NSSI) and suicidal ideation (SI) as well as NSSI and suicide attempt (SA). In addition, trauma exposure has been implicated in risk for NSSI and suicide. Genetically informative studies are needed to determine common sources of liability to all three self-injurious thoughts and behaviors, and to clarify the nature of their associations with traumatic experiences.

METHODS

Multivariate biometric modeling was conducted using data from 9526 twins [59% female, mean age = 31.7 years (range 24-42)] from two cohorts of the Australian Twin Registry, some of whom also participated in the Childhood Trauma Study and the Nicotine Addiction Genetics Project.

RESULTS

The prevalences of high-risk trauma exposure (HRT), NSSI, SI, and SA were 24.4, 5.6, 27.1, and 4.6%, respectively. All phenotypes were moderately to highly correlated. Genetic influences on self-injurious thoughts and behaviors and HRT were significant and highly correlated among men [rG = 0.59, 95% confidence interval (CI) (0.37-0.81)] and women [rG = 0.56 (0.49-0.63)]. Unique environmental influences were modestly correlated in women [rE = 0.23 (0.01-0.45)], suggesting that high-risk trauma may confer some direct risk for self-injurious thoughts and behaviors among females.

CONCLUSIONS

Individuals engaging in NSSI are at increased risk for suicide, and common heritable factors contribute to these associations. Preventing trauma exposure may help to mitigate risk for self-harm and suicide, either directly or indirectly via reductions in liability to psychopathology more broadly. In addition, targeting pre-existing vulnerability factors could significantly reduce risk for life-threatening behaviors among those who have experienced trauma.

Suicidal attempts among patients with substance use disorders who present with suicidal ideation

BACKGROUND AND AIMS

Patients with addictions have a great risk of suicidal ideation and attempts. Suicidal behaviour is a continuum that begins with ideation and may continue with planning, attempts and suicide completion. Investigating the specific risk characteristics for suicidal attempts in patients with addiction problems who present with suicidal ideation is crucial for developing prevention strategies. The main aims of this study were to determine the prevalence rate of suicide attempts among patients with lifetime suicidal ideation receiving treatment for addiction, and to explore the differential characteristics for suicide ideators with and without suicide attempts.

METHODS

A sample of 149 patients with suicidal ideation (110 male and 39 female) who sought treatment for addiction in a Spanish clinical centre was assessed.

MEASUREMENTS

Information concerning socio-demographic characteristics, addiction severity, and psychopathological symptoms was obtained.

RESULTS

In total, 39.6% of the patients had attempted suicide (95% Confidence Interval: 32.1%-47.6%). Although all patients with suicidal behaviours presented a high severity in their addiction, patients with both suicidal ideation and suicide attempts showed a more severe addiction profile and more maladjustment to everyday life than patients with only suicidal ideation. Specifically, three psychopathological variables were related to suicide attempts: worse psychiatric state, previous hospitalization for psychological problems, and history of delirium.

CONCLUSIONS

According to the results, a systematic screening of suicidal risk in patients seeking treatment for addiction problems is recommended. Addiction treatment centres should develop treatment strategies to prevent suicidal ideators from attempting suicide, mainly in those cases with a worse lifetime psychiatric condition.

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.

Non-suicidal self-injury in Chinese heroin-dependent patients receiving methadone maintenance treatment: Prevalence and associated factors

BACKGROUND

To date, there have been no studies examining non-suicidal self-injury (NSSI) in Chinese heroin-dependent patients (HDPs) receiving methadone maintenance treatment (MMT). This study determined the prevalence of NSSI and its methods in HDPs under MMT as well as factors significantly associated with NSSI.

METHOD

We recruited a cross-sectional sample of 652 HDPs from three MMT clinics in Wuhan, China. In total, 603 HDPs (92.5%) completed standardized questionnaires concerning demographic, clinical, and psychosocial data. The presence and methods of NSSI were assessed with two standardized questions.

RESULTS

The one-month prevalence of NSSI in Chinese HDPs receiving MMT was 13.8%. The most common three methods of NSSI were burning (59%), cutting (19.3%), and hitting (9.6%). Significant factors associated with NSSI in multiple logistic regression analysis were unemployment (OR [95%CI] = 2.54 [1.26, 5.10], P = 0.009), a short duration of MMT (OR [95%CI] = 1.04 [1.01, 1.09], P = 0.034), pain (OR [95%CI] = 2.31 [1.05, 5.35], P = 0.028), depression (OR [95%CI] = 4.32 [2.09, 9.00], P < 0.001), anxiety (OR [95%CI] = 3.74 [1.61, 8.70], P = 0.002), and loneliness (OR [95%CI] = 3.04 [1.27, 7.26], P = 0.012).

CONCLUSIONS

NSSI is common among Chinese HDPs of MMT clinics. Services for HDPs in MMT settings should include periodic screening for NSSI, adequate pain treatment, and appropriate psychosocial treatment for depression, anxiety, and loneliness.

Suicidal Ideation and Suicide Attempts among Women Seeking Treatment for Substance Use and Trauma Symptoms

Substance use disorders and posttraumatic stress disorder have been associated with suicide. Through secondary analysis of the screening data from the Women and Trauma Study conducted by the National Institute on Drug Abuse Clinical Trials Network, the present study examined rates and correlates of suicidal ideation and suicide attempts among women who sought treatment for substance use and trauma at seven outpatient substance use programs. The sample included women between the ages of 18 and 65 years (M = 39.2; SD = 9.3) and was 44 percent white, 33 percent African American, 8 percent Latina, and 15 percent other races or ethnicities. Logistic regression was used to examine factors associated with a lifetime history of recurrent suicidal ideation and a serious suicide attempt. Findings highlight the need for social workers to address elevated risk levels for suicidal thoughts and behaviors when working with women with histories of substance use and trauma.

Prevalence of Deliberate Self-harm Among Chinese Patients With Heroin Dependence: A Meta-Analysis

Background: There is paucity of data regarding the prevalence and methods of deliberate self-harm (DSH) in patients with heroin dependence in international literature. In China, there have been a few studies investigating the prevalence of DSH in heroin-dependent patients (HDPs), but their rates varied widely. We thus conducted a meta-analysis of studies assessing the prevalence of DSH among Chinese HDPs. Methods: Relevant studies were retrieved from major Chinese databases (China National Knowledge Infrastructure, Wanfang data, and SinoMed) and western databases (PubMed, EMBASE, and PsycInfo). Two authors independently identified eligible studies and extracted data. Studies that included a representative sample of Chinese HDPs and ascertained DSH caseness in a reliable way were considered as high quality. Statistical analysis was performed using R software. Results: In total, 15 eligible studies with a total of 37,243 Chinese HDPs were included. All included studies were conducted in heroin detoxification settings. Only two studies were rated as high quality. The pooled prevalence of DSH in Chinese HDPs was 4.4% (95%CI: 2.9, 6.2%), but the heterogeneity of prevalence rates across studies was significant (I² = 98%, P < 0.001). Studies rated as high quality had significantly higher prevalence of DSH than those rated as low quality (13.2 vs. 3.4%, P < 0.001). Swallowing foreign objects was the most common method of DSH, with a combined prevalence of 2.7% (95%CI: 1.6, 4.4%). Extreme DSH methods such as cutting off fingers and jumping from height were also not uncommon in this patient population. Conclusion: Due to methodological problems in available studies, we find a relatively low prevalence of DSH among Chinese HDPs receiving detoxification treatment. Nevertheless, the self-harmers of Chinese HDPs are more likely to harm themselves in a dangerous or life-threatening way. Restricting the availability of DSH methods may be an effective way to prevent or reduce DSH in China's detoxification treatment settings.

The aggressor at the mirror: Psychiatric correlates of deliberate self-harm in male prison inmates

BACKGROUND

Deliberate self-harm (DSH) causes important concern in prison inmates as it worsens morbidity and increases the risk for suicide. The aim of the present study is to investigate the prevalence and correlates of DSH in a large sample of male prisoners.

METHODS

A cross-sectional study evaluated male prisoners aged 18+ years. Current and lifetime psychiatric diagnoses were assessed with the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders - DSM-IV Axis I and Axis II Disorders and with the Addiction Severity Index-Expanded Version. DSH was assessed with The Deliberate Self-Harm Inventory. Multivariable logistic regression models were used to identify independent correlates of lifetime DSH.

RESULTS

Ninety-three of 526 inmates (17.7%) reported at least 1 lifetime DSH behavior, and 58/93 (62.4%) of those reported a DSH act while in prison. After multivariable adjustment (sensitivity 41.9%, specificity 96.1%, area under the curve=0.854, 95% confidence interval CI=0.811-0.897, P<0.001), DSH was significantly associated with lifetime psychotic disorders (adjusted Odds Ratio aOR=6.227, 95% CI=2.183-17.762, P=0.001), borderline personality disorder (aOR=6.004, 95% CI=3.305-10.907, P<0.001), affective disorders (aOR=2.856, 95% CI=1.350-6.039, P=0.006) and misuse of multiple substances (aOR=2.024, 95% CI=1.111-3.687, P=0.021).

CONCLUSIONS

Borderline personality disorder and misuse of multiple substances are established risk factors of DSH, but psychotic and affective disorders were also associated with DSH in male prison inmates. This points to possible DSH-related clinical sub-groups, that bear specific treatment needs.

Lifetime suicide attempt history, quality of life, and objective functioning among HIV/AIDS patients with alcohol and illicit substance use disorders

This cross-sectional study evaluated lifetime prevalence of suicide attempts in 170 HIV/AIDS patients with substance use disorders and the impact of suicide attempt history on subjective indices of quality of life and objective indices of cognitive and physical functioning. All patients met the diagnostic criteria for past-year cocaine or opioid use disorders and 27% of patients also had co-occurring alcohol use disorders. Compared to their counterparts without a history of a suicide attempt, patients with a history of a suicide attempt (n = 60, 35.3%) had significantly poorer emotional and cognitive quality of life scores (ps < .05), but not physical, social, or functional/global quality-of-life scores. Lifetime suicide attempt status was unrelated to objective indices of cognitive functioning, but there was a non-significant trend (p = .07) toward lower viral loads in those with a lifetime suicide attempt relative to those without. The findings indicate that suicide attempt histories are prevalent among HIV/AIDS patients with substance use disorders and relate to poorer perceived emotional and cognitive quality of life, but not objective functioning. HIV/AIDS patients with substance use disorders should be screened for lifetime histories of suicide attempts and offered assistance to improve perceived emotional and cognitive functioning.

Relations between Nonsuicidal Self-Injury and Suicidal Behavior in Adolescence: A Systematic Review

Nonsuicidal self-injury (NSSI) and suicidal behaviors, both important issues in adolescent health care, are frequently associated and possibly clinically related. Our objective was to explore the views of relations between nonsuicidal self-injury and suicidal behaviors during adolescence and young adulthood (11–25 years) expressed in the scientific (medical and psychological) literature. We adopted a textual approach to the process of synthesis to tell the story of the findings from the included studies. Our narrative systematic review of 64 articles found that they share the same risk factors. Integrated models envision nonsuicidal self-injury as a gateway enabling teens to acquire the capability for suicide. Because suicidal behavior short-circuits thought, it is difficult to conceive an intention to die during adolescents' acts of self-injury. Intention is constructed by the narrative of the act, influenced by numerous elements from the psychopathologic, cultural, religious, and philosophic context. Techniques of mentalizing-based treatments and work on the meaning that adolescents attribute to their behaviors might improve care.

Subjective pain during NSSI as an active agent in suicide risk

Non-suicidal self-injury (NSSI) has been identified as a correlate and predictor of suicidal ideation and attempts. Given the high-rates of NSSI presence among adolescents and young adults, it is important to identify specific characteristics of NSSI that might place individuals who engage in this behavior at highest risk for suicidal behavior. NSSI is thought to increase the acquired capability for suicide via habituation to self-harm, though the NSSI characteristics most responsible for this relationship are unclear. The current study examined three characteristics of NSSI (frequency, number of methods, and subjective pain) that may help to elucidate this risk relationship. University students (N=997) with a history of NSSI completed measures assessing lifetime NSSI frequency, number of NSSI methods employed, and subjective experience of pain during NSSI, as well as suicide attempt (SA) history. Results indicated that NSSI frequency, number of NSSI methods, and subjective pain experienced during NSSI were each positively associated with SA history. Further, subjective pain experienced during NSSI moderated the relationship between NSSI frequency and SA history, such that the association between NSSI frequency and SA history was stronger for individuals who experienced lower levels of subjective pain.

Identifying a physical indicator of suicide risk: Non-suicidal self-injury scars predict suicidal ideation and suicide attempts

BACKGROUND

Suicide risk is challenging to quantify due to reliance on self-report, which is limited by individuals' lack of insight and the desire to conceal such intentions. Non-suicidal self-injury (NSSI) is one of the most robust predictors of suicidal ideation (SI) and suicide attempts (SA). Although NSSI often leads to permanent scarring, which can be assessed by objective physical examination, no research has examined whether scarring denotes tangible risk for SI and SA. The present study examined whether NSSI scar presence and number predict current SI and SA history. Further, we examined whether brooding would exacerbate the effects of NSSI scarring on SI or SA.

METHODS

Young adults (N=231; M=21.24 years; 78% female) completed self-report questionnaires assessing SA history, frequency of NSSI, presence/number of NSSI scars, brooding, current depressive symptoms, and SI.

RESULTS

NSSI scar presence and number predicted current SI and SA history after controlling for current depressive symptoms. Moreover, scar presence and number predicted current SI over and above the effects of SA history and NSSI frequency, method, and medical severity. Further, NSSI scar presence and number predicted SI more strongly among individuals with greater levels of brooding than among individuals with lower levels of brooding.

CONCLUSIONS

The presence and number of NSSI scars are objective physical indicators of risk for SI and SAs. Brooding may further heighten the risk of SI for individuals bearing NSSI scars.

Licit and illicit substance use among people who inject drugs and the association with subsequent suicidal attempt

AIM

To estimate associations between recent licit and illicit substance use and subsequent suicide attempt among people who inject drugs (PWID).

DESIGN

Secondary analysis of longitudinal data from a prospective cohort study of PWID followed bi-annually between 2004 and 2011.

SETTING

Montréal, Canada.

PARTICIPANTS

Seven hundred and ninety-seven PWID who reported injection drug use in the previous 6 months, contributing to a total of 4460 study visits. The median number of visits per participant was five (interquartile range: 3-8).

MEASUREMENTS

An interviewer-administered questionnaire eliciting information on socio-demographic factors, detailed information on substance use patterns and related behaviours, mental health markers and suicide attempt. The primary exposure variables examined were past-month use of alcohol [heavy (≥ 60 drinks); moderate (one to 59 drinks); none], sedative-hypnotics, cannabis, cocaine, amphetamine and opioids [regular (≥ 4 days); occasional (1-3 days); none]. The outcome was a binary measure of suicide attempt assessed in reference to the previous 6 months.

FINDINGS

In multivariate analyses, a positive association was found among licit substances between heavy alcohol consumption [adjusted odds ratio (AOR) = 2.05; 95% confidence interval (CI) = 1.12-3.75], regular use of sedative-hypnotics (AOR = 1.89; 95% CI = 1.21-2.95) and subsequent attempted suicide. Among illicit substances, occasional use of cannabis (AOR = 1.84; 95% CI = 1.09-3.13) had a positive association with subsequent suicide attempt. No statistically significant association was found for the remaining substances.

CONCLUSION

Among people who inject drugs, use of alcohol, sedative-hypnotics and cannabis, but not cocaine, amphetamine or opioids, appears to be associated with an increased likelihood of later attempted suicide.

Patterns and correlates of attempted suicide amongst heroin users: 11-year follow-up of the Australian treatment outcome study cohort

Lifetime and recent rates of attempted suicide and suicidal ideation amongst the Australian Treatment Outcome Study cohort of heroin users at 11-year follow-up were examined. The mean elapsed time since heroin initiation was 20.4 years. At 11-year follow-up, 42.2% of the cohort reported ever having made a suicide attempt, 11.1% having made a first attempt subsequent to baseline. In the year preceding 11-year follow-up, 1.6% had made an attempt, suicidal ideation was reported by 10.4%, and 4.2% had a current suicide plan. After controlling for other variables, past 12 month attempts, current ideation or plans were independently associated with a current diagnosis of Major Depression (odds ratios (OR) 1.67) and more extensive polydrug use (OR 1.39), while each standard deviation higher on the SF12 physical health scale (reflecting better health) was associated with reduced odds (OR 0.66). Suicide and suicidal ideation remained a significant clinical issue for heroin users, some 20 years after their heroin use commenced.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Frequency and functions of non-suicidal self-injury: associations with suicidal thoughts and behaviors

Previous research has found associations between non-suicidal self-injury (NSSI) and suicidal thoughts and behaviors (STBs), yet the nature of this relationship remains equivocal. The goal of the present study was to examine how lifetime NSSI frequency and individual NSSI functions relate to a history of suicidal ideation, plan, and attempt. Data were collected via a large (N=13,396) web-based survey of university students between the ages of 18 and 29. After demographics and psychiatric conditions were controlled for, we found a positive curvilinear relationship between NSSI frequency and each of the suicide outcomes. When examined among those with STBs, bipolar disorder and problematic substance use remained positively associated with risk for suicide attempt, but not NSSI. Analyses of individual NSSI functions showed differential associations with STBs of varying severity. Specifically, nearly every NSSI function was significantly related to suicide attempt, with functions related to avoiding committing suicide, coping with self-hatred, and feeling generation (anti-dissociation) showing the strongest risks for suicide attempt. From both clinical and research perspectives, these findings suggest the importance of assessing multiple reasons for engaging in self-injury.

The association of childhood physical abuse with the onset and extent of drug use among regular injecting drug users

AIMS

To determine whether childhood physical abuse (CPA) histories were associated with age of onset of psychoactive substance use and injecting, and the extent of polydrug use among injecting drug users (IDU).

DESIGN

Cross-sectional.

SETTING

Sydney, Australia.

PARTICIPANTS AND MEASUREMENTS

A total of 300 IDU were administered a structured interview examining the prevalence and severity of CPA and drug use histories.

FINDINGS

Of the participants, 40.3% had experienced severe abuse (SA), 34.0% mild-moderate abuse (MMA) and 25.7% no abuse history (NA). After controlling for other variables, a history of severe CPA was a significant independent correlate of an earlier age at first alcohol intoxication compared to both the NA (β = -0.23, P < 0.01) and MMA (β = 0.20, P < 0.01) groups. Severe CPA was also a significant independent correlate of an earlier age at first illicit drug use compared to both the NA (β = -0.16, P < 0.05) and MMA (β = -0.15, P < 0.05) groups. In contrast, CPA histories were not independently associated with the onset of injecting drug use. After controlling for potential confounders, both the MMA (β = 0.28, P < 0.001) and SA (β = 0.27, P < 0.001) groups were associated with more extensive life-time polydrug use, but did not differ from each other (P = 0.82). After controlling for potential confounders, both MMA (β = 0.20, P < 0.01) and SA (β = 0.33, P < 0.001) group membership were associated with more extensive recent polydrug use but, again, did not differ significantly from each other (P = 0.08).

CONCLUSIONS

Severe childhood physical abuse severity is associated with an earlier initiation into drug use. Any level of abuse is associated with more extensive life-time and recent polydrug use.

Childhood physical abuse, non-suicidal self-harm and attempted suicide amongst regular injecting drug users

BACKGROUND

Childhood physical abuse (CPA), non-suicidal self-harm and attempted suicide are all highly prevalent amongst injecting drug users (IDU). This paper reported on the association of CPA with self-harm and attempted suicide.

METHODS

Cross-sectional study, with 300 IDU administered a structured interview examining the prevalence of CPA, non-suicidal self-harm and suicide attempts.

RESULTS

CPA was reported by 74.3%, and severe CPA by 40.3%. A history of non-suicidal self-harm was reported by 23.7%, and 25.7% had attempted suicide. Non-suicidal self-harm preceded the suicide attempt in 83.3% of cases where both had occurred. Independent correlates of non-suicidal self-harm were: female gender (OR 3.62), avoided home due to conflict (OR 2.28) and more extensive polydrug use (OR 1.32). Independent correlates of attempted suicide were: severe CPA (OR 3.18), frequent CPA (OR 2.54), avoided home due to conflict (OR 3.95), female gender (OR 2.99), a positive screen for Conduct Disorder (OR 3.53), and more extensive polydrug use (OR 1.52).

CONCLUSIONS

Those presenting to treatment agencies are highly likely to have a history of CPA, that may still influence their behaviours. Screening for histories of CPA and non-suicidal self-harm appears warranted when determining suicide risk for this population. At the population level, reductions in the rate of CPA, could possibly reduce the rate of subsequent suicidality.

Hospitalizations for suicide-related drug poisonings and co-occurring alcohol overdoses in adolescents (ages 12-17) and young adults (ages 18-24) in the United States, 1999-2008: results from the Nationwide Inpatient Sample

Drug poisoning is the leading method of suicide-related deaths among females and third among males in the United States. Alcohol can increase the severity of drug poisonings, yet the prevalence of alcohol overdoses in suicide-related drug poisonings (SRDP) remains unclear. Data from the Nationwide Inpatient Sample was examined to determine rates of inpatient hospital stays for SRDP and co-occurring alcohol overdoses in adolescents (ages 12-17) and young adults (ages 18-24) between 1999 and 2008. Among adolescents, there were 14,615 hospitalizations for drug poisonings in 2008, of which 72% (10,462) were suicide-related at a cost of $43 million. Rates of SRDP in this age group decreased between 1999 and 2008. The prevalence of co-occurring alcohol overdoses increased from 5% in 1999 to 7% in 2008. Among young adults, there were 32,471 hospitalizations for drug poisonings in 2008, of which 64% (20,746) were suicide-related at a cost of $110 million. Rates of SRDP did not change significantly between 1999 and 2008. The prevalence of co-occurring alcohol overdoses increased from 14% in 1999 to 20% in 2008. Thus, while rates of SRDP decreased for adolescents and remained unchanged for young adults, the prevalence of co-occurring alcohol overdoses increased for both age groups. Such hospitalizations provide important opportunities to employ intervention techniques to prevent further suicide attempts.

Lifetime trauma exposure and posttraumatic stress disorder in women sentenced to drug court

The aims of this study were to characterize trauma exposure and posttraumatic stress disorder (PTSD) in female drug court participants and test for differences in socioeconomic status and familial status between women with: (i) no trauma exposure, (ii) trauma exposure without PTSD, and (iii) trauma exposure resulting in PTSD. Three hundred and nineteen women were recruited from drug courts. Rates of exposure and likelihood of traumatic events leading to PTSD were examined, sociodemographic characteristics were compared across groups, and a logistic regression analysis was conducted to test for differences in PTSD risk for assaultive vs. non-assaultive events. Twenty percent of participants met PTSD criteria, 71% had trauma exposure without PTSD, and 9% did not endorse any traumatic events. Prostitution and homelessness were more prevalent in women with vs. without a history of trauma, but among trauma-exposed women prevalences did not vary by PTSD status. No differences in risk for PTSD were found between assaultive and non-assaultive events (OR=0.91; 95%CI: 0.48-1.75). Women sentenced to drug court represent a heavily trauma-exposed population, for whom risk for PTSD is not limited to assaultive events. Within this high-risk population, trauma is associated with elevated rates of homelessness and prostitution, even in the absence of PTSD.

Examining the link between nonsuicidal self-injury and suicidal behavior: a review of the literature and an integrated model

Self-injurious behaviors (SIB) refer to behaviors that cause direct and deliberate harm to oneself, including nonsuicidal self-injury (NSSI), suicidal behaviors, and suicide. Although in recent research, NSSI and suicidal behavior have been differentiated by intention, frequency, and lethality of behavior, researchers have also shown that these two types of self-injurious behavior often co-occur. Despite the co-occurrence of NSSI and suicidal behavior, however, little attention has been given as to why these self-injurious behaviors may be linked. Several authors have suggested that NSSI is a risk factor for suicidal behavior, but no comprehensive review of the literature on NSSI and suicidal behavior has been provided. To address this gap in the literature, we conducted an extensive review of the research on NSSI and suicidal behavior among adolescents and adults. First, we summarize several studies that specifically examined the association between NSSI and suicidal behavior. Next, three theories that have been proposed to account for the link between NSSI and suicidal behavior are described, and the empirical support for each theory is critically examined. Finally, an integrated model is introduced and several recommendations for future research are provided to extend theory development.

Mortality and causes of death among violent offenders and victims--a Swedish population based longitudinal study

BACKGROUND

Most previous studies on mortality in violent offenders or victims are based on prison or hospital samples, while this study analyzed overall and cause specific mortality among violent offenders, victims, and individuals who were both offenders and victims in a general sample of 48,834 18-20 year-old men conscripted for military service in 1969/70 in Sweden.

METHODS

Each person completed two non-anonymous questionnaires concerning family, psychological, and behavioral factors. The cohort was followed for 35 years through official registers regarding violent offenses, victimization, and mortality. The impact of violence, victimization, early risk factors and hospitalization for psychiatric diagnosis or alcohol and drug misuse during follow up on mortality was investigated using Cox proportional hazard regression analyses.

RESULTS

Repeat violent offenses were associated with an eleven fold higher hazard of dying from a substance-related cause and nearly fourfold higher hazard of dying from suicide. These figures remained significantly elevated also in multivariate analyses, with a 3.03 and 2.39 hazard ratio (HR), respectively. Participants with experience of violence and inpatient care for substance abuse or psychiatric disorder had about a two to threefold higher risk of dying compared to participants with no substance use or psychiatric disorder.

CONCLUSIONS

Violent offending and being victimized are associated with excess mortality and a risk of dying from an alcohol or drug-related cause or suicide. Consequently, prevention of violent behavior might have an effect on overall mortality and suicide rates. Prevention of alcohol and drug use is also warranted.