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Mental disease in a forensic autopsy population of alcoholics
SCIENTIFIC & TECHNICAL
Mental disease in a forensic autopsy population of alcoholics JL THOMSEN University Institute of Forensic Science, Winslowparken 17, DK-5000 Odense C, Denmark Science & Justice 1996; 36: 89-92 Received 21 November 1994; accepted 26 June 1995
A retrospective examination of fatalities was carried out during a five-year period among alcoholics in Copenhagen who had undergone forensic examination. The frequency of mental disease was compared with that among a nonalcoholic control group. In an examination of 2298 deaths, it was found that alcoholics had a higher frequency of unipolar affective disorder and of general 'nervousness'. Previous suicide attempts were more frequent in alcoholics, and both alcoholics and controls had a higher frequency of previous suicide attempts among the depressed and those who later committed suicide than among those who did not.
Fiir einen Zeitraum von 5 Jahren sind fiir Kopenhagen kriminaltechnisch untersuchte Todesfdlle unter Alkoholikern riickblickend ausgewertet worden. Verglichen wurde die Haufigkeit von Geisteskrankheiten mit derjenigen bei Nichtalkoholikern. Bei insgesamt 2298 ausgewerteten Todesfllen waren die Haufigkeit von Verhaltensstorungen und die allgemeine nervliche Erregbarkeit bei Alkoholabhangigen deutlich hoher. Die Zahl der vorangegangenen Selbstmordversuche war ebenfalls haufiger. Die Zahl der Selbstmordversuche und Selbstmorde von Alkoholikern unterscheidet sich jedoch nicht von derjenigen depressiv veranlagter Nichtalkoholiker.
Un examen ritrospectif a CtC effectuC sur les dCcbs pendant une ptriode de cinq ans parmi les alcooliques de Copenhague qui avaient CtC examinks en mCdecine 1Cgale. La frCquence de maladie mentale a CtC comparCe avec celle dans un groupe de contr6le non alcoolique. Dans l'examen de 2'298 morts, il a CtC trouvC que les alcooliques avaient une frkquence plus ClevCe de dCsordre affectif unipolaire et de "nervosit6" gCnCrale. Les tentatives de suicide prCalables Ctaient plus frkquentes chez les alcooliques et aussi bien les alcooliques que les contr6les avaient une plus grande frkquence de tentative de suicide prCalable parmi les dCprimCs et ceux qui ont commis un suicide subsCquent que parmi le reste de la population.
Se realiz6 un estudio retrospectivo de un period0 de cinco aiios sobre muertes de alcoh6licos de Copenhague, a 10s que se les habia realizado la autopsia. Se cornpard la frecuencia de enfermedades mentales con las de otro grupo control de no-alcoh6licos. En un examen de 2298 muertes se encontr6 que 10s alcoh6licos tenian una mayor frecuencia de trastornos afectivos unipolares y de 'nerviosismo' general. Los intentos de suicidio previos fueron m5s frecuentes en 10s alcoh6licos, y tanto 10s alcoh6licos como 10s control tenian una frecuencia de intentos de suicidio mayor entre 10s que sufrian depresi6n y 10s que luego se suicidaron que entre 10s que luego no lo hicieron.
Key Words: Forensic science; Alcoholism; Medico-legal; Mental disease; Depression; Suicide attempts; Denmark. Science & Justice 1996; 36(2): 89-92
89
Mental disease in a forensic autopsy population of alcoholics
Introduction It is a general conception that alcoholics suffer a higher frequency of psychiatric problems including affective disorders. They often die an unnatural death by homicide or accident, or by suicide, in which the mental disease may be of importance. Most studies of mental disease in alcoholics have been in live patients. The aim of the present retrospective investigation was to compare a group of alcoholics with a control group of non-alcoholics, using the forensic examination records of all cases examined during the period from 1985 to 1989 at the University Institute of Forensic Pathology in Copenhagen, which is the only forensic institution for the county of Copenhagen. According to Danish law, a physician must report any sudden and unexpected deaths to the police; these would include actual or suspected homicide, accident or suicide, deaths caused by an occupational disease or by medical malpractice; or deaths in detention, prison, etc. An external forensic examination would then be performed by a medical health officer. A medico-legal autopsy would only be performed if a crime had been committed, or was suspectTABLE 1 Sex distribution of the four groups studied with percentages in parentheses.
ALC.AU
Male 317 (72)
Female 124 (28)
CON.AU
168 (66)
87 (34)
255 (100)
ALC.EX
650 (80)
158 (20)
808 (100)
CON.EX
386 (49)
408 (51)
794 (100)
1521 (66)
777 (34)
2298 (loo)
Group
Total
Total 441
ed, if the manner of death was not known, or if the cause of death was not known and the case held aspects of interest to the police. The Minister of Justice may further decide that cases of special interest to society must undergo a medicolegal autopsy. Since 1970, this rule has been applied to all cases of death in connection with drug abuse. At the examination all available material is present including hospital records, information from the general practitioner and police records.
Material and methods Four groups were therefore selected from among those examined at the Institute during the period from 1985 to 1989. In order to be included in the alcoholic groups, the Coroners Act (Ligsynsloven) must have been applicable, death must have occurred in Copenhagen County, and alcohol abuse must have been documented. Two alcoholic groups were studied: 441 cases who had undergone a medico-legal autopsy (ALC.AU) and 808 cases who had been examined externally by a forensic examiner (ALC.EX). The control groups comprised 255 and 794 cases respectively, every tenth case of age 18 years and over in which there was no information of alcohol abuse and in which a forensic autopsy had been performed (CON.AU), and every fifteenth case of age 18 years and over in which there was no information of alcohol abuse and in which only an external examination had been carried out (CON.EX). Results Table 1 shows the sex distribution in the four groups of 2298 cases examined. The only significant difference was that between the two non-autopsied groups, women were
TABLE 2 The distribution of mental diseases in the four groups studied. Mental Illness
ALC.AU (%)
C0N.AU (%)
ALC.EX (%)
CON.EX (%)
Total (%)
None Schizophrenia Manic-depression Depression Neurosis Character Neurosis Alcoholic Dementia Senility 'Nervousness' Retardation Other Total 90
Science & Justice 1996; 36(2):89-92
more frequent in CON.EX than in ALC.EX (x2 = 176.20, DF = 1, p<< I%), introducing a possible bias in the comparison. Table 2 shows the frequency of mental disease in the four groups. There was no significant difference in the frequency of manic-depressive disease. Alcoholics (ALC.AU and ALC.EX) had, however, a significantly higher frequency of other types of depression as compared with controls (CON.AU + CON.EX) ( 2 = 13176, DF = 1, P < 1 %). With regard to nervousness, this term was used significantly more often in alcoholics than in controls (x2= 6.77, DF = 1, p < 1%). There were only a few cases of alcoholic dementia and of schizophrenia, evenly distributed in the groups. In Table 3 it can be seen that both manic depressive alcoholics and controls showed a significantly higher suicide frequency than in the rest of the autopsy material with a known manner of death. In other types of depression there was also a much higher frequency of suicides both among alcoholics and controls as compared to the rest of the autopsy material with known manner of death. Of the 175 deceased who had made previous suicide attempts, 46 (ALC.AU) and 69 (ALC.EX) were in the alcoholic groups and 15 (CON.AU) and 45 (CON.EX) were controls. The frequency in the two groups of alcoholics was significantly higher than in the controls (x2= 9.37, DF = 1, p < 1%). The frequency of previous suicide attempts was higher among both alcoholics and controls known to be depressed than in those in whom there was no history of depression. Among those who had committed suicide, there was a significantly higher number who had made previous
TABLE 3 Suicide frequency in groups of alcoholics and controls (DF = 1, p < 1%), (percentagesin parentheses). Alcoholic group Control group
Manic depression No manic depression 2
13117 (76.5) 20711132 (18.3) 33.06
Other depression No other depression 2
1391202 (68.8) 8 11947 (8.6) 386.62
Previous suicide attempts depressed no depression x2
581216 (26.9) 5511021 (5.4) 96.39
Suicide after previous attempts
681220 (30.9)
Non-suicide despite previous attempts
371932 (4)
2
152.69
Science & Justice 1996; 36(2): 89-92
attempts than among those who did not commit suicide.
Discussion External forensic examinations were carried out on between 16 and 17% of all deaths during the period of study, and between 4 and 5% were autopsied. It is important to emphasize that neither in the autopsied groups nor in those with only an external examination was alcoholism a selection criterion for forensic examination. The investigation was thus not a comprehensive account of deaths among alcoholics, but could only describe all deaths in the material selected for forensic examination, with an overrepresentation of non-natural deaths. However, since the alcoholics and the controls were selected on exactly the same criteria, the results will probably reliably show differences caused by alcoholism. The social parameters of the materials were as previously described [I]. There were no differences in, for example, social class as most of the cases of both alcoholics and controls belonged to the lowest social class. It is not possible in forensic material to classify alcoholism according to internationally accepted guidelines such as those of the World Health Organisation (WHO) [lo] or DSM-III-R [ll], as a thorough history including possible withdrawal symptoms is not easily obtainable. Forensic cases classified as alcoholics usually represent a very substantial and long-lasting abuse that will easily satisfy the classifications mentioned above. Significantly, the controls could include an unknown number of alcoholics in whom the abuse was not so substantial as to be known and mentioned. This might on the other hand tend to blur the differences between alcoholics and controls, so that the differences could be regarded as more reliable. It must also be emphasized that it is similarly not possible in post mortem retrospective studies to classify mental diseases exactly as laid down by the World Health Organisation [lo]. The diagnosis ante mortem was usually made by a physician, such as the general practitioner or a psychiatrist in a hospital ward or in an outpatient clinic for alcoholics. The term 'nervousness' is broad and covers a wide spectrum of non-specific mental symptoms deviating from normal, but without a regular psychiatric diagnosis. The closest in ICD-10 [lo] to cover this spectrum of symptoms is probably 'Disorder of personality' (F60.9). Undoubtedly the term was alsa used about cases who would not have been categorized as suffering from a mental disease when examined by a psychiatrist. There might even be a greater tendency to overdiagnose in the alcoholics than in controls due to the abnormal behaviour in the former, when under the influence of alcohol. This could introduce a bias, unavoidable in a retrospective investigation.As some of the subgroups used for statistical comparisons were rather
Mental disease in a forensic autopsy population of alcoholics
small, type 2 errors (an existing difference not detected) are possible. As the study included police records with thorough interviews of relatives, neighbours, physicians, etc., it is likely that most of the information regarding previous suicide attempts had been obtained. It is difficult to find reports of comparable studies. This investigation was the first to include a comparable control material, and the use of forensic autopsy material was rather unusual. However, Davidson [2] concluded on the basis of examination of 82 patients that depression may be due to the effect of chronic alcohol intoxication. In a consecutive series of 339 alcoholics, Roy et a1 [3] found 81% with mental disease. In the same material they found [4] that 33% suffered major depression, which is higher than in the present investigation. In an interview investigation of 20291 persons in the USA, Regier et a1 [5] found that 36.4% of persons with an alcohol abuse problem suffered from some kind of mental disease. This is also somewhat higher than in the present study. Based on that same material, Helzer and Pryzbeck concluded that 'the association between alcoholism and depressive disorders was positive but not very strong' [6]. Bronisch [7] found a higher frequency of depression in alcoholics, but these depressive disorders were usually not very serious. In a previous Danish investigation in alcohol abusers in the Copenhagen area [8] psychosis was found in 2.1%, neurosis/character neurosis in 1.6%, personality disorder in lo%, drug abuse in 4.8%, affective disorder in 1.8%, other diagnoses in 1.6%. Altogether 21.9% of the abusers had a psychiatric diagnosis. This frequency is a little lower than that found in the present study. In an interesting report [9], Irwin et a1 found a decreased activity of 'killer cells', both in depressed persons and in alcoholics, but more pronounced in depressed alcoholics. This might be one of the reasons for the well-known decreased resistance against infections in alcoholics. The higher frequency of suicides in the depressed and of previous suicide attempts in the depressed and in those who succeeded in committing suicide was not surprising. The
alcoholics did not differ from the controls in that respect. In the present study, the two groups of cases were selected on the same criteria; the differences must therefore be due to alcoholism. It cannot, of course, be decided if these differences were a consequence of alcohol abuse or a possible predisposing factor. The same tendency towards a higher frequency of mental disease in alcoholics has been found by other workers.
References 1. Thomsen JL. Chronic alcoholism in a forensic autopsy material. Social parameters in alcoholics. Medicine, Science and the Law (in mess). . . 2. Davidson KM. Diagnosis of Depression in Alcohol Dependence: Changes in Prevalence with Drinking Status. British Journal of Psychiatry 1995; 166: 199-204. 3. Roy A, DeJong J, Lamparski D, Adinoff B, George T, Moore V, Garnett D, Kerich M and Linnoila M. Mental disorders among alcoholics. Relationship to age of onset and cerebrospinal fluid neuropeptides. Archives of General Psychiatry 1991; 48: 423427. 4. Roy A, DeJong J, Lamparski D, George T and Linnoila M. Depression among alcoholics. Relationship to clinical and cerebrospinal fluid variables. Archives of General Psychiatry 1991; 48: 428432. 5. Regier DA, Farmer ME, Rae DS, Locke BZ, Keith SJ, Judd LL and Goodwin FK. Comorbidity of mental disorders with alcohol and other drug abuse. Results from the Epidemiologic Catchment Area (ECA) Study [see comments]. Journal of the American Medical Association 1990; 264: 25 11-2518. 6. Helzer JE and Pryzbeck TR. The co-occurrence of alcoholism with other psychiatric disorders in the general population and its impact on treatment. Journal of Studies on Alcohol 1988; 49: 219-224. 7. Bronisch T. Zur Beziehung zwischen Alkoholismus und Depression anhand eines iiberblicks iiber empirische Studien. Fortschritte der Neurologie-Psychiatric 1985; 53: 454-468 (abstract in English). 8. Sogaard U, Naylor AS, Knop J, Thusholt FJ and Holm Jensen EO. Alkohol-misbrugere ved de psykiatriske skadestuer i Kobenhavn og p i Frederiksberg. Ugeskrift for Laeger 1991; 153: 567-570 (abstract in English). 9. Irwin M, Caldwell C, Smith TL, Brown S, Schuckit MA and Gillin JC. Major depressive disorder, alcoholism, and reduced natural killer cell cytotoxicity. Role of severity of depressive symptoms and alcohol consumption. Archives of General Psychiatry 1990; 47: 713-719. 10. The ICD-10 Classification of Mental and Behavioral Disorders. Geneva, World Health Organisation, 1992. 11. Diagnostic and Statistical Manual of Mental Disorders. 3rd Edition Revised. New York, American Psychiatric Association, distributed by Cambridge University Press, 1987.
Science & Justice 1996; 36(2):89-92
Mental disease in a forensic autopsy population of alcoholics JL THOMSEN University Institute of Forensic Science, Winslowparken 17, DK-5000 Odense C, Denmark Science & Justice 1996; 36: 89-92 Received 21 November 1994; accepted 26 June 1995
A retrospective examination of fatalities was carried out during a five-year period among alcoholics in Copenhagen who had undergone forensic examination. The frequency of mental disease was compared with that among a nonalcoholic control group. In an examination of 2298 deaths, it was found that alcoholics had a higher frequency of unipolar affective disorder and of general 'nervousness'. Previous suicide attempts were more frequent in alcoholics, and both alcoholics and controls had a higher frequency of previous suicide attempts among the depressed and those who later committed suicide than among those who did not.
Fiir einen Zeitraum von 5 Jahren sind fiir Kopenhagen kriminaltechnisch untersuchte Todesfdlle unter Alkoholikern riickblickend ausgewertet worden. Verglichen wurde die Haufigkeit von Geisteskrankheiten mit derjenigen bei Nichtalkoholikern. Bei insgesamt 2298 ausgewerteten Todesfllen waren die Haufigkeit von Verhaltensstorungen und die allgemeine nervliche Erregbarkeit bei Alkoholabhangigen deutlich hoher. Die Zahl der vorangegangenen Selbstmordversuche war ebenfalls haufiger. Die Zahl der Selbstmordversuche und Selbstmorde von Alkoholikern unterscheidet sich jedoch nicht von derjenigen depressiv veranlagter Nichtalkoholiker.
Un examen ritrospectif a CtC effectuC sur les dCcbs pendant une ptriode de cinq ans parmi les alcooliques de Copenhague qui avaient CtC examinks en mCdecine 1Cgale. La frCquence de maladie mentale a CtC comparCe avec celle dans un groupe de contr6le non alcoolique. Dans l'examen de 2'298 morts, il a CtC trouvC que les alcooliques avaient une frkquence plus ClevCe de dCsordre affectif unipolaire et de "nervosit6" gCnCrale. Les tentatives de suicide prCalables Ctaient plus frkquentes chez les alcooliques et aussi bien les alcooliques que les contr6les avaient une plus grande frkquence de tentative de suicide prCalable parmi les dCprimCs et ceux qui ont commis un suicide subsCquent que parmi le reste de la population.
Se realiz6 un estudio retrospectivo de un period0 de cinco aiios sobre muertes de alcoh6licos de Copenhague, a 10s que se les habia realizado la autopsia. Se cornpard la frecuencia de enfermedades mentales con las de otro grupo control de no-alcoh6licos. En un examen de 2298 muertes se encontr6 que 10s alcoh6licos tenian una mayor frecuencia de trastornos afectivos unipolares y de 'nerviosismo' general. Los intentos de suicidio previos fueron m5s frecuentes en 10s alcoh6licos, y tanto 10s alcoh6licos como 10s control tenian una frecuencia de intentos de suicidio mayor entre 10s que sufrian depresi6n y 10s que luego se suicidaron que entre 10s que luego no lo hicieron.
Key Words: Forensic science; Alcoholism; Medico-legal; Mental disease; Depression; Suicide attempts; Denmark. Science & Justice 1996; 36(2): 89-92
89
Mental disease in a forensic autopsy population of alcoholics
Introduction It is a general conception that alcoholics suffer a higher frequency of psychiatric problems including affective disorders. They often die an unnatural death by homicide or accident, or by suicide, in which the mental disease may be of importance. Most studies of mental disease in alcoholics have been in live patients. The aim of the present retrospective investigation was to compare a group of alcoholics with a control group of non-alcoholics, using the forensic examination records of all cases examined during the period from 1985 to 1989 at the University Institute of Forensic Pathology in Copenhagen, which is the only forensic institution for the county of Copenhagen. According to Danish law, a physician must report any sudden and unexpected deaths to the police; these would include actual or suspected homicide, accident or suicide, deaths caused by an occupational disease or by medical malpractice; or deaths in detention, prison, etc. An external forensic examination would then be performed by a medical health officer. A medico-legal autopsy would only be performed if a crime had been committed, or was suspectTABLE 1 Sex distribution of the four groups studied with percentages in parentheses.
ALC.AU
Male 317 (72)
Female 124 (28)
CON.AU
168 (66)
87 (34)
255 (100)
ALC.EX
650 (80)
158 (20)
808 (100)
CON.EX
386 (49)
408 (51)
794 (100)
1521 (66)
777 (34)
2298 (loo)
Group
Total
Total 441
ed, if the manner of death was not known, or if the cause of death was not known and the case held aspects of interest to the police. The Minister of Justice may further decide that cases of special interest to society must undergo a medicolegal autopsy. Since 1970, this rule has been applied to all cases of death in connection with drug abuse. At the examination all available material is present including hospital records, information from the general practitioner and police records.
Material and methods Four groups were therefore selected from among those examined at the Institute during the period from 1985 to 1989. In order to be included in the alcoholic groups, the Coroners Act (Ligsynsloven) must have been applicable, death must have occurred in Copenhagen County, and alcohol abuse must have been documented. Two alcoholic groups were studied: 441 cases who had undergone a medico-legal autopsy (ALC.AU) and 808 cases who had been examined externally by a forensic examiner (ALC.EX). The control groups comprised 255 and 794 cases respectively, every tenth case of age 18 years and over in which there was no information of alcohol abuse and in which a forensic autopsy had been performed (CON.AU), and every fifteenth case of age 18 years and over in which there was no information of alcohol abuse and in which only an external examination had been carried out (CON.EX). Results Table 1 shows the sex distribution in the four groups of 2298 cases examined. The only significant difference was that between the two non-autopsied groups, women were
TABLE 2 The distribution of mental diseases in the four groups studied. Mental Illness
ALC.AU (%)
C0N.AU (%)
ALC.EX (%)
CON.EX (%)
Total (%)
None Schizophrenia Manic-depression Depression Neurosis Character Neurosis Alcoholic Dementia Senility 'Nervousness' Retardation Other Total 90
Science & Justice 1996; 36(2):89-92
more frequent in CON.EX than in ALC.EX (x2 = 176.20, DF = 1, p<< I%), introducing a possible bias in the comparison. Table 2 shows the frequency of mental disease in the four groups. There was no significant difference in the frequency of manic-depressive disease. Alcoholics (ALC.AU and ALC.EX) had, however, a significantly higher frequency of other types of depression as compared with controls (CON.AU + CON.EX) ( 2 = 13176, DF = 1, P < 1 %). With regard to nervousness, this term was used significantly more often in alcoholics than in controls (x2= 6.77, DF = 1, p < 1%). There were only a few cases of alcoholic dementia and of schizophrenia, evenly distributed in the groups. In Table 3 it can be seen that both manic depressive alcoholics and controls showed a significantly higher suicide frequency than in the rest of the autopsy material with a known manner of death. In other types of depression there was also a much higher frequency of suicides both among alcoholics and controls as compared to the rest of the autopsy material with known manner of death. Of the 175 deceased who had made previous suicide attempts, 46 (ALC.AU) and 69 (ALC.EX) were in the alcoholic groups and 15 (CON.AU) and 45 (CON.EX) were controls. The frequency in the two groups of alcoholics was significantly higher than in the controls (x2= 9.37, DF = 1, p < 1%). The frequency of previous suicide attempts was higher among both alcoholics and controls known to be depressed than in those in whom there was no history of depression. Among those who had committed suicide, there was a significantly higher number who had made previous
TABLE 3 Suicide frequency in groups of alcoholics and controls (DF = 1, p < 1%), (percentagesin parentheses). Alcoholic group Control group
Manic depression No manic depression 2
13117 (76.5) 20711132 (18.3) 33.06
Other depression No other depression 2
1391202 (68.8) 8 11947 (8.6) 386.62
Previous suicide attempts depressed no depression x2
581216 (26.9) 5511021 (5.4) 96.39
Suicide after previous attempts
681220 (30.9)
Non-suicide despite previous attempts
371932 (4)
2
152.69
Science & Justice 1996; 36(2): 89-92
attempts than among those who did not commit suicide.
Discussion External forensic examinations were carried out on between 16 and 17% of all deaths during the period of study, and between 4 and 5% were autopsied. It is important to emphasize that neither in the autopsied groups nor in those with only an external examination was alcoholism a selection criterion for forensic examination. The investigation was thus not a comprehensive account of deaths among alcoholics, but could only describe all deaths in the material selected for forensic examination, with an overrepresentation of non-natural deaths. However, since the alcoholics and the controls were selected on exactly the same criteria, the results will probably reliably show differences caused by alcoholism. The social parameters of the materials were as previously described [I]. There were no differences in, for example, social class as most of the cases of both alcoholics and controls belonged to the lowest social class. It is not possible in forensic material to classify alcoholism according to internationally accepted guidelines such as those of the World Health Organisation (WHO) [lo] or DSM-III-R [ll], as a thorough history including possible withdrawal symptoms is not easily obtainable. Forensic cases classified as alcoholics usually represent a very substantial and long-lasting abuse that will easily satisfy the classifications mentioned above. Significantly, the controls could include an unknown number of alcoholics in whom the abuse was not so substantial as to be known and mentioned. This might on the other hand tend to blur the differences between alcoholics and controls, so that the differences could be regarded as more reliable. It must also be emphasized that it is similarly not possible in post mortem retrospective studies to classify mental diseases exactly as laid down by the World Health Organisation [lo]. The diagnosis ante mortem was usually made by a physician, such as the general practitioner or a psychiatrist in a hospital ward or in an outpatient clinic for alcoholics. The term 'nervousness' is broad and covers a wide spectrum of non-specific mental symptoms deviating from normal, but without a regular psychiatric diagnosis. The closest in ICD-10 [lo] to cover this spectrum of symptoms is probably 'Disorder of personality' (F60.9). Undoubtedly the term was alsa used about cases who would not have been categorized as suffering from a mental disease when examined by a psychiatrist. There might even be a greater tendency to overdiagnose in the alcoholics than in controls due to the abnormal behaviour in the former, when under the influence of alcohol. This could introduce a bias, unavoidable in a retrospective investigation.As some of the subgroups used for statistical comparisons were rather
Mental disease in a forensic autopsy population of alcoholics
small, type 2 errors (an existing difference not detected) are possible. As the study included police records with thorough interviews of relatives, neighbours, physicians, etc., it is likely that most of the information regarding previous suicide attempts had been obtained. It is difficult to find reports of comparable studies. This investigation was the first to include a comparable control material, and the use of forensic autopsy material was rather unusual. However, Davidson [2] concluded on the basis of examination of 82 patients that depression may be due to the effect of chronic alcohol intoxication. In a consecutive series of 339 alcoholics, Roy et a1 [3] found 81% with mental disease. In the same material they found [4] that 33% suffered major depression, which is higher than in the present investigation. In an interview investigation of 20291 persons in the USA, Regier et a1 [5] found that 36.4% of persons with an alcohol abuse problem suffered from some kind of mental disease. This is also somewhat higher than in the present study. Based on that same material, Helzer and Pryzbeck concluded that 'the association between alcoholism and depressive disorders was positive but not very strong' [6]. Bronisch [7] found a higher frequency of depression in alcoholics, but these depressive disorders were usually not very serious. In a previous Danish investigation in alcohol abusers in the Copenhagen area [8] psychosis was found in 2.1%, neurosis/character neurosis in 1.6%, personality disorder in lo%, drug abuse in 4.8%, affective disorder in 1.8%, other diagnoses in 1.6%. Altogether 21.9% of the abusers had a psychiatric diagnosis. This frequency is a little lower than that found in the present study. In an interesting report [9], Irwin et a1 found a decreased activity of 'killer cells', both in depressed persons and in alcoholics, but more pronounced in depressed alcoholics. This might be one of the reasons for the well-known decreased resistance against infections in alcoholics. The higher frequency of suicides in the depressed and of previous suicide attempts in the depressed and in those who succeeded in committing suicide was not surprising. The
alcoholics did not differ from the controls in that respect. In the present study, the two groups of cases were selected on the same criteria; the differences must therefore be due to alcoholism. It cannot, of course, be decided if these differences were a consequence of alcohol abuse or a possible predisposing factor. The same tendency towards a higher frequency of mental disease in alcoholics has been found by other workers.
References 1. Thomsen JL. Chronic alcoholism in a forensic autopsy material. Social parameters in alcoholics. Medicine, Science and the Law (in mess). . . 2. Davidson KM. Diagnosis of Depression in Alcohol Dependence: Changes in Prevalence with Drinking Status. British Journal of Psychiatry 1995; 166: 199-204. 3. Roy A, DeJong J, Lamparski D, Adinoff B, George T, Moore V, Garnett D, Kerich M and Linnoila M. Mental disorders among alcoholics. Relationship to age of onset and cerebrospinal fluid neuropeptides. Archives of General Psychiatry 1991; 48: 423427. 4. Roy A, DeJong J, Lamparski D, George T and Linnoila M. Depression among alcoholics. Relationship to clinical and cerebrospinal fluid variables. Archives of General Psychiatry 1991; 48: 428432. 5. Regier DA, Farmer ME, Rae DS, Locke BZ, Keith SJ, Judd LL and Goodwin FK. Comorbidity of mental disorders with alcohol and other drug abuse. Results from the Epidemiologic Catchment Area (ECA) Study [see comments]. Journal of the American Medical Association 1990; 264: 25 11-2518. 6. Helzer JE and Pryzbeck TR. The co-occurrence of alcoholism with other psychiatric disorders in the general population and its impact on treatment. Journal of Studies on Alcohol 1988; 49: 219-224. 7. Bronisch T. Zur Beziehung zwischen Alkoholismus und Depression anhand eines iiberblicks iiber empirische Studien. Fortschritte der Neurologie-Psychiatric 1985; 53: 454-468 (abstract in English). 8. Sogaard U, Naylor AS, Knop J, Thusholt FJ and Holm Jensen EO. Alkohol-misbrugere ved de psykiatriske skadestuer i Kobenhavn og p i Frederiksberg. Ugeskrift for Laeger 1991; 153: 567-570 (abstract in English). 9. Irwin M, Caldwell C, Smith TL, Brown S, Schuckit MA and Gillin JC. Major depressive disorder, alcoholism, and reduced natural killer cell cytotoxicity. Role of severity of depressive symptoms and alcohol consumption. Archives of General Psychiatry 1990; 47: 713-719. 10. The ICD-10 Classification of Mental and Behavioral Disorders. Geneva, World Health Organisation, 1992. 11. Diagnostic and Statistical Manual of Mental Disorders. 3rd Edition Revised. New York, American Psychiatric Association, distributed by Cambridge University Press, 1987.
Science & Justice 1996; 36(2):89-92