Suicide is an important public health problem. It is surprising, therefore, that it has so often been underrecognized. Suicide is a major cause of death. In most European countries, it ranks among the 10 most frequent causes of mortality.1 According to the United Kingdom's Registrar-General, approximately 5,000 suicides are currently recorded each year in the UK, 10 times higher than the number of homicides. Suicide accounts for nearly 1% of all deaths in England and Wales.
In the United States, it has been estimated that there are about 600,000 attempted suicides each year, with suicide itself accounting for the deaths of more than 30,000 people.2 It would be reasonable to expect preventive policies to give a similar priority to suicide as to automobile accident deaths, which have a comparable prevalence.
Kessler, Borges, and Walters3 presented nationally representative data on the prevalence and risk factors for attempted suicide in the US National Comorbidity Survey. This included general population survey data on the lifetime prevalence of suicide attempts as well as data about the onset of suicidal ideation, the development of suicidal plans, and suicidal attempts. Among the respondents, 13.5% reported lifetime suicidal ideation, and 4.6% reported having made an attempt. In a study of data from the Epidemiologic Catchment Area Study, Moscicki et al.4 estimated that 4.3% of their sample had made a suicide attempt.
Suicide can be found among all members of the population, although certain groups are at special risk. Although numerically more elderly than young people die by suicide, it is one of the leading causes of death among adolescents and young adults.5 More young adults in the US die as a result of suicide than from all natural causes of death combined (including HIV/AIDS and all other medical conditions).6 Death rates among adolescents in the US doubled between 1960 and 2001,7 and there has been a great deal of concern in recent years about the high and increasing rates of suicide among young people. Suicide accounts for about 14% of all deaths among people 15 to 24 in the US.8
The Role of Alcohol
The association between suicide and alcohol use and misuse has been shown in many studies using different methods. Roy et al.9 found consumption of a greater amount of alcohol during drinking episodes was associated with increased risk of suicidal behaviors. Hawton, Fagg, and McKeoun10 reported that alcohol consumption was more likely to occur during the period immediately preceding the suicide attempt.
Early onset of alcohol or substance use problems also appears to increase the risk of suicide. Buydens-Branchey et al.11 found patients who had started abusing alcohol in their teens were four times more likely to have attempted suicide than those who started abusing alcohol later in life. Hesselbrock et al.12 also found early onset of heavy drinking was associated with increased rates of suicide attempts. In addition, alcohol use among completed suicides has been found to be more common among those with no previous psychiatric history.13
Crombie et al.13 reported that nearly half (45%) of their suicide cases had consumed alcohol prior to death, and 19% were found to be drunk at the time of suicide. Various measures of alcohol consumption and of alcohol misuse problems have been found to be related to suicide. Powell et al.14 found that drinking frequency, drinking quantity, binge drinking, alcoholism, drinking within 3 hours of suicide attempts, and age of drinking onset were all associated with serious suicide attempts. However, among those who were current nonusers of drugs or alcohol, previous substance use was not found to be a significant predictor of suicidal behavior.15
Among adolescents, alcohol misuse and other forms of substance use increase risk of suicidal behaviors.16 Clinical and community studies have found alcohol use to be associated with attempted and completed suicide.17,18 Severity of alcohol misuse problems among adolescents also has been found to be associated with attempted suicide. In a longitudinal study, Reifman and Windle19 found increasing alcohol consumption was predictive of future suicidal behaviors among adolescents.
High rates of association between alcohol and suicide deaths also have been found in certain specific subgroups. For example, in a study of Native Americans, May et al.20 reported that alcohol was detected in 69% of all completed suicides from toxicology reports.
It commonly is assumed that alcohol use and misuse lead to an increased risk of suicidal ideation, suicide attempts, and completed suicide. However, most of the available evidence regarding alcohol and suicide is indirect or correlational. There are several different possible relationships between alcohol use and suicidal behaviors: alcohol use may affect suicidal ideation and behaviors (and not the reverse); suicidal ideation may affect alcohol use (and not the reverse); alcohol use and suicidal phenomena may affect each other; alcohol use may not itself affect suicide but may aggravate other factors that affect suicide; or alcohol use and suicidal behaviors may each be affected by some third factor without themselves being directly related. The precise nature of the relationship between alcohol and suicidal behaviors is not properly understood.
A variety of psychological, physiological, and social hypotheses have been proposed to explain how alcohol use might influence suicide ideation and behaviors. It is possible, for example, that the effects of drinking or acute intoxication may lead to increased suicidal ideation or behaviors. Substance misuse has been found to increase the number of unplanned suicide attempts among those with suicidal ideation, and alcohol and drug use have both been found to be predictive of subsequent suicide attempts after controlling for sociodemographics and comorbid mental disorders.21 Increasing doses of alcohol also may produce dysphoric effects such as anxiety, irritability and sadness.22
Alcohol may serve to increase feelings of hopelessness by its toxic effects, by possible effects on the neurotransmitters responsible for the regulation of mood and judgment, and by disruption of interpersonal relationships and social supports.23 The effects of alcohol may increase suicidal ideation or may reduce the barriers to acting on suicidal thoughts or impulses. Alcohol may lead to behavioral disinhibition and may adversely affect judgment. Heavy drinking over prolonged periods may undermine social relationships and social support networks and may alienate others in the social environment.
The self-medication hypothesis suggests that depressed and suicidal feelings can lead to increased alcohol use. Suicidal ideation also typically leads to high levels of anxiety and stress.24 In this context, alcohol often is used as a short-term anxiolytic drug. Indeed, alcohol can be used as a readily available form of self-medication to alleviate distressing symptoms associated with many types of psychological problems.25 It is possible that some of the observed association between alcohol use and suicidal phenomena may be due to the use of alcohol as a coping mechanism for suicidal ideation. Use of alcohol to self-medicate dysphoric mood can lead to a complication of the underlying problems.
It is possible that the observed associations between alcohol and suicide may be due to some third factor. A predisposition to anxiety or depression could have this sort of effect. Another option could involve certain types of personality factors, such as high levels of impulsivity, which might independently lead to an increased probability of both alcohol misuse and suicidal behaviors.
In studies of adolescents, suicidal ideation and suicide attempts have been found to be related to substance misuse.26 Evidence suggests a significant association between use of psychoactive substances and suicidal behavior among adolescents.27 Substance use disorders tend to be associated with a range of suicidal behaviors, including suicidal ideation, attempted suicide, and completed suicide. Substance use disorders also appear to be associated with a greater frequency of suicide attempts, more medically lethal attempts, greater seriousness of intention, and greater suicidal ideation. Additional data support a specific association between alcohol intoxication and suicide involving fire-arms among US adolescents.36
In 1998, Berglund and Ojehagen28 reviewed the published literature on the influence of alcohol use and alcohol use disorders upon psychiatric disorders and suicidal behavior. In both epidemiologic and clinical studies, the results indicated a high comorbidity of substance use disorders and other mental disorders and showed that alcohol abuse worsens the course of psychiatric disorders. Light to moderate alcohol consumption was not found to be related to suicide. In countries with a high per capita alcohol consumption, the suicide rate was also high, and this tended to increase with per capita levels of alcohol consumption.
Alcohol-related effects may be influenced by sociocultural and environmental factors. In a study of two countries with different alcohol use patterns, Norstrom29 found that alcohol consumption was more strongly related to suicide in Sweden than in France. In a Swedish study, Bradvik and Berglund30 presented data to suggest the variation of suicide by day of the week among patients with alcohol dependence. The study showed that there was a suicide peak among patients with alcohol dependence on the first 2 days after weekends and holidays. In a study of suicide attempters in the US, Canada, Mexico, and Australia, Borges et al.15 found a positive association between suicide attempts and alcohol use in the previous 6 hours.
There are also suggestions that specific beverage types may be relevant. Gruenewald, Ponicki, and Mitchell31 investigated the relationships between suicide rates and specific measures of alcohol consumption in the US. Time series cross-sectional analyses of the data for different states showed suicide rates were associated specifically with liquor sales, and that while suicide rates increased significantly as a function of increased liquor sales, beer and wine sales were not associated with suicide rates. Such findings may relate to different choices of beverage type by different drinkers. Heroin addicts, for example have been found to prefer stronger forms of alcohol to less potent drinks such as beer or wine.32
Other Risk Factors
In addition to substance use disorders, many other circumstances and problems can put a person at increased risk of suicide. These may include psychiatric disorders, social factors (such as loss of employment, bereavement, or aging), neurochemical and biological factors, genetic factors, and physical and medical problems.
A number of risk factors tend to occur in clusters. Alcohol misuse, for example, tends to be associated with mental health problems. There is also a great deal of clinical heterogeneity in the psychiatric disorders experienced by people with drinking problems. Because alcohol problems and psychiatric disorders are both common, it is to be expected that there would be some degree of overlap in any population. However, anxiety and depressed mood have been found in many studies to be more prevalent among people receiving treatment for alcohol misuse problems than in the general population. In addition, large numbers of those who present to alcohol treatment services have some sort of psychiatric comorbidity problems.
In the Epidemiologic Catchment Area study, Regier et al.33 reported that more than a third (37%) of those in the general population with an alcohol disorder also experienced another psychiatric disorder. Some of the most common comorbid disorders were anxiety (19%), affective disorders (13%), and schizophrenia (4%).34 Slightly higher levels of comorbidity were reported in the US National Co-Morbidity Survey.3 The evidence for lifetime comorbidity was stronger among those with alcohol dependence than among those with alcohol abuse, and comorbidity was more commonly found among women than men.
The British Psychiatric Morbidity Survey provided a national survey of three populations: a household population, a population of patients who were resident in psychiatric institutions, and a homeless population. Farrell et al.35 reported rates of current and 12-month alcohol dependence of 5% among the household sample, 7% for the institutional sample, and 21% among the homeless sample. Both heavy drinking and alcohol dependence were associated with higher rates of psychological morbidity.
Various forms of psychiatric comorbidity, and particularly mood disorders, have been found to be associated with increased risk of suicidal behaviors when they co-occur with substance use disorders.28,36,37 Kessler et al.3 found each disorder from the Diagnostic and Statistical Manual of Mental Disorders, third edition – revised (DSM-III-R),38 that was assessed in the National Comorbidity Survey was a significant risk factor for a lifetime suicide attempt. Mood disorders were a stronger risk factor than any other disorder. The finding that mood disorders are stronger predictors than other mental or substance use disorders is consistent with the results from other studies. Depression is one of the most common disorders among people who commit suicide.12,39
Among adolescents, the risk of suicidal behaviors is increased among those with substance misuse problems.40 Rates of depression also are higher among adolescent substance misusers, although it remains unclear if substance use leads to depression, if depression leads to substance use, or if either may occur depending on the patient. Kelly et al.41 found that adolescents with substance use disorders were most likely to attempt suicide when they also had a mood disorder.
In a New Zealand study, Conner et al.37 collected data on completed suicides, medically serious suicide attempters, and controls. Mood disorders were more frequent among suicide completers and medically serious attempters than controls. Patients completing suicide were also older and more likely to be male. In a study of the association between impulsivity and aggression with suicidal ideation in adolescents and young adults, Conner et al.42 found impulsivity and irritability were associated strongly with suicidal ideation.
Cornelius et al.43 also suggested that, while a mood disorder alone may not be sufficient to increase suicide risk, risk is heightened among people with a mood disorder who subsequently develop an alcohol use disorder. Although depression is the form of psychiatric comorbidity most often associated with suicidal behavior, other psychological disorders also have been implicated. Wunderlich et al.,18 for example, found anxiety disorders to be the most significant risk for attempted suicide in their study of a large community sample of adolescents and young adults. The effect of psychiatric comorbidity may be general rather than specific. Kessler et al.3 found a relationship between attempted suicides and the number of previous psychiatric diagnoses.
Some occupational groups are at increased risk, and rates of suicide have been found to be higher in certain occupations. Physicians, for example, have a relatively high risk of suicide.44 The reasons for this are unclear, although the easy access to a range of lethal methods and exposure to intense and often prolonged occupational stress both have been suggested.44
The work of physicians and other healthcare professionals also places them at risk of both physical and mental health problems, including problems associated with the misuse of drugs and alcohol.45,46 It is common for physicians to drink heavily at early stages of their careers. Birch et al.47 found about two-thirds of recently qualified physicians exceeded recommended safe drinking limits, while 10% were drinking at hazardous levels. The British Medical Association estimated that as many as 1 in 15 physicians may be affected by drug or alcohol dependence problems at some point during their careers.48 Although more is known about alcohol misuse among physicians, those working in other healthcare professions are also at risk of developing drug problems. Concern about healthcare professionals has been expressed in relation to medical students, physicians, dentists, nurses, and pharmacists.46
Alcohol Abuse and Dependence
Alcohol abuse and alcohol dependence are known to be strongly associated with suicide. Suicidal ideations and suicide attempts are relatively common among alcoholics, especially those with comorbid major depression or bipolar disorder.43 Crombie et al.13 suggested alcoholics may account for between 20% and 40% of all suicides, and Beck and Steer49 found alcoholism was the strongest single predictor of subsequent completed suicide in a sample of attempted suicides. Prospective studies have suggested that 7% of alcoholics die as a result of suicide.50 Retrospective postmortem studies have consistently reported that at least one-third of those whose death was due to suicide met criteria for alcohol abuse or dependence.51
Driessen et al.52 found that a history of suicide attempts was reported by 29% of a sample of alcohol-dependent inpatients at admission to treatment. In other studies, it has been suggested that between one-fifth and one-third of the increased death rate among alcoholics is attributable to suicide.28 Alcoholics frequently threaten suicide, and many go on to make suicide attempts. Murphy53 suggested more than half of alcoholics who commit suicide had talked previously about committing suicide.
Others also have drawn attention to the high rates of association between substance misuse disorders and suicide. Miller, Mahler, and Gold23 suggested that more than 50% of all suicides are associated with alcohol and drug dependence, that at least 25% of alcoholics and drug addicts commit suicide, and that more than 70% of adolescent suicides may be complicated by drug and alcohol use and dependence.
Hesselbrock et al.12 examined the association between drinking problems and suicide attempts in a sample of hospitalized alcoholics. Suicide attempters were more likely to have multiple psychiatric diagnoses and more severe psychiatric symptoms than nonattempters. Alcoholics who subsequently go on to complete suicide also have been found to have a higher rate of depressive symptoms than alcoholics who do not complete suicide.54
Driessen et al.52 found both anxiety and depressive disorders were associated with suicidal ideation among a sample of alcohol-dependent people seeking in-patient detoxification treatment. In this study, the authors suggested psychiatric comorbidity was of greater importance in leading to suicidal risk than was the alcohol dependence disorder. The relative importance of alcohol and psychiatric comorbidity as suicide risk factors may vary in different populations and in different circumstances.
Using data collected during a large multiple-group case control study, Conner et al.55 examined the hypothesized roles of gender, age, and mood disorder as moderators of the effects of alcohol dependence. The risk for suicide associated with alcohol dependence was found to increase with age. The results of this controlled study show that middle-aged and older adults with alcoholism were especially at risk for suicide and suggest that mood disorder acts as a more powerful risk factor for suicide among problem drinkers as age increases.
The association between alcohol and suicide is further complicated because a majority of people with substance use problems take a range of different substances.56 Large numbers of those who seek treatment for drug dependence also have problematic patterns of drinking. Many of the drug misusers in treatment in the US are problematic drinkers.57 Among drug misusers seeking treatment in the UK, more than one third of those who were drinking at intake to treatment reported problematic patterns of alcohol consumption.58
Alcohol and cocaine frequently are used together. The concurrent use of alcohol and cocaine has been reported in the general population,59 and it has been estimated that as many as 30% to 60% of alcohol dependent patients also use cocaine.60 Borges, Walters, and Kessler21 found that the number of substances used was more important than the types of substances used in predicting suicidal behavior. These authors concluded that current substance use, even in the absence of abuse or dependence, is a significant risk factor for unplanned suicide attempts.
The use of alcohol–drug combinations also may have direct effects that increase the risk of overdose or other serious adverse reactions. When cocaine and alcohol are taken together, the two substances interact to produce cocaethylene, an active metabolite with a half-life three times that of cocaine and that is more cardiotoxic than cocaine.61 The combined use of alcohol with opiates or sedative drugs has been found to be common among drug misusers who have taken both nonfatal62,63 and fatal64 overdoses. The alcohol–heroin combination increases the risk of death as a result of increased respiratory depression.
When suicide occurs in conjunction with substance misuse, this may lead to a problem of misclassification and, in particular, to deaths due to suicidal intent being misclassified as accidental overdose. The use of alcohol with illicit drugs increases the risk of mortality as a result of both intentional and unintentional overdoses.
It is encouraging that increasing attention is being paid to the problem of suicide. Current UK government policy has identified the reduction of suicide as a priority national target for intervention. However, despite the increased research attention that has been paid to suicide and its association with alcohol use, this relationship is still not well understood.
It has been known for many years that the great majority of suicide victims communicate their suicidal intentions,65 and many see physicians in the period before they commit suicide. In this respect, the majority of suicides could be regarded as being, at least in principle, preventable. However, little is known about the immediate precursors of suicide and it is extremely difficult to attempt to predict suicidal behavior in individual cases. Attempts to predict infrequent behaviors such as suicide inevitably tend to produce a large number of false positives and false negatives.
Miller, Mahler, and Gold23 suggested alcohol and drug misuse disorders are sufficiently important risk factors for suicidal behavior and suicide that all those with substance use disorders should be assessed for suicide, especially if they are actively using alcohol or drugs. Cornelius et al.43 said alcohol-dependent patients should be assessed for suicidal ideations when they exhibit significant levels of other depressive symptoms or when they suffer a relapse of alcohol or drug use. Also, because many alcoholics and substance abusers report suicidal ideations, especially at the end of a binge or in the very early phase of withdrawal, such assessments may be indicated at these times. Conner et al.37 proposed that suicide risk recognition and prevention efforts should be geared toward middle-aged and older adults with alcohol dependence and mood disorders.
Others have made suggestions relevant for specific high-risk groups. Hawton, Malmberg, and Simkin44 said the prevention of suicide in doctors requires a range of strategies, including reduced occupational stress, improved management of psychiatric disorder, and restriction of access to means of suicide during episodes of depression.
Healthcare professionals who encounter adolescents with both depression and substance misuse problems should be alert to the high-risk status of these patients.40 Garnefski and De Wilde66 recommended that when younger adolescents present with multiple drug misuse disorders, and with drug dependence disorders involving drugs such as heroin or crack cocaine, suicidal intention or suicidal risk should always be assessed. Suicidal adolescents also may be seen in emergency departments. This provides a further important opportunity for intervention that may be missed because of inadequate assessment, unsympathetic staff attitudes, and inadequate training.67
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