- Email: [email protected]
Relationship between alcohol consumption and attempted suicide morbidity rates in Perth, Western Australia, 1968–1984
Addictive Behaviors,
Vol. 16, pp. 57-61, Printed in the USA. All rights reserved.
1991 Copyright
0306-4603191 $3.00 + .oO c 1991 Pergamon Press plc
BRIEF REPORT RELATIONSHIP BETWEEN ALCOHOL CONSUMPTION AND ATTEMPTED SUICIDE MORBIDITY RATES IN PERTH, WESTERN AUSTRALIA, 196th1984 D. IAN SMITH and PETER W. BURVILL University
of Western Australia
Abstract - Per adult (2 15 years) consumption of beer, wine, spirits, and absolute alcohol for a 17-year period (1968-1984) was related to the attempted suicide morbidity rates in the Perth urban area of Western Australia. For both males and females aged 15-39 years, Mann-Whitney U tests showed that during the years of highest spirits consumption, the highest rates for attempted suicide occurred. A similar finding also applied to 15-39-year-old males for wine. The effect of a rapidly rising blood alcohol level. together with a preselection factor as to the personal characteristics of persons who consumed the higher alcohol content drinks, may explain the results, which need to be confirmed by clinical studies of the typ of alcoholic beverage consumed by persons prior to attempting suicide.
Attempted suicide is by no means a homogeneous phenomenon. For instance, differences in rates between males and females, and between younger and older persons have been documented. Of relevance to this article, suicide attempters tend to be young, with a preponderance of females, who frequently display depression and make their attempt on impulse (Weissman, 1974). A number of studies have also shown that alcohol is a factor of some importance in the aetiology of attempted suicide. Roizen (1982) summarised the results of 17 surveys and found that 15-64% of the persons included in each study consumed alcohol prior to their suicide attempt. Similar findings were reported by Kendell (1983). From a clinical perspective, research has shown that those identified as being at risk for suicide attempts tend to be depressed, maladjusted, and have poor control over their often excessive drinking. In addition to its effect of impairing judgment, alcohol can give a person the courage to act on impulse and attempt suicide, and especially for persons with a history of alcohol-related problems (Ritson, 1977). Not surprisingly, therefore, among persons entering alcohol treatment programmes, the attempted suicide rate can be quite high (Schuckit, 1986). Of 50 attempted suicide patients admitted to Royal Perth Hospital in Western Australia, 28% had blood alcohol levels in excess of 0.15% (150 mg/lOO mL), while a further 34% had levels between 0.05% and 0.15% (James, Scott-Orr, & Cumow, 1963). The researchers commented that alcohol intoxication seemed to be the main factor in attempted suicide for some unstable persons, and to act as a trigger for a suicide attempt for others. Although liver cirrhosis is an alcohol-related problem that can take lo-15 years to develop, changes in the overall community level of alcohol consumption have been shown to quickly influence liver cirrhosis morbidity rates (Smith & Burvill, 1985). Similarly, the We wish to thank the Statistics Branch of the Health Department of Western Australia for supplying the morbidity data used for the study. Requests for reprints should be sent to D. Ian Smith, Ph.D., WA Alcohol and Drug Authority, 35 Havelock Street, West Perth, 6005 Australia. 57
D. IAN SMITH and PETER W. BURVILL
58
Table 1. Mann-Whitney U tests comparing attempted suicide morbidity rates in the Perth Statistical Division for the eight highest and eight lowest years of beer, wine, spirits, and absolute alcohol consumption from 1968 to 1984 Age-Sex Group Males 15-39 Males 40+ Females 15-39 Females 40+
Beer
Wine
21 32 36 34
10* 32 38 48
Spirits 15 26 1** 22
Absolute Alcohol 18 37 39 42
Two-tail tests were used. *p < 0.05. **p c: 0.01.
more alcohol a community consumes, the greater is the likelihood that people will have access to alcohol at times of suicidal impulses. Consequently, it can be predicted that there should be a positive relationship between the level of alcohol consumption in a community, and the rate of attempted suicide. If so, this would have important implications for prevention initiatives, for it would suggest that by reducing overall alcohol consumption the rate of attempted suicide could be reduced (Kendell, 1983). Wallgren and Barry (1970) stated that many of the effects of alcohol depend not only on the concentration achieved, but also on the rate of rise of the concentration. For instance, reports of more violent intoxication after consuming equal quantities of alcohol as spirits rather than as beer are consistent with the effect of a rapid rise in the blood alcohol level (BAL), as demonstrated by Gustafson and Klllmen (1988). This raises the possibility that if a person’s BAL is rapidly rising, the likelihood of the person attempting suicide may be greater than for a slowly rising BAL, and in particular because of the greater distortion of judgment, mood, and emotions of drinkers. If correct, the hypothesis that follows is that the higher the alcohol content of a beverage, the more likely it is to be related to attempted suicide. Support for this prediction comes from a previous study (Smith, 1990) that found that spirits consumption was closely related to the rates of (a) charges for homicide and (b) emergency hospital admissions caused by injury purposely inflicted by other persons. The aim of this study was to investigate the relationship between attempted suicide rates and alcohol consumption in the community. and in particular to test the hypothesis that the higher the alcohol content of a beverage. the more closely should that beverage be related to variations in the attempted suicide rates. METHOD
In Western Australia, virtually all admissions for attempted suicide are made to general hospitals, whether they are public or private hospitals. By contrast, many of the admissions to mental health hospitals for attempted suicide are, in effect, discharges from general hospitals. Consequently, the data base for the study was restricted to general hospital admissions for attempted suicide coded E950-958 (WHO, 1967, 1977) during the period 1968-1984. Admissions caused by the late effects of self-inflicted injury (E959) were omitted from the study. The Ninth Revision of the International Classification of Diseases (WHO, 1977) was used to code admissions after January 1, 1979. The study was restricted to admissions in the Perth Statistical Division, the capital city urban area of Western Australia. Attempted suicide morbidity rates were calculated for males
Alcohol consumption/attempted
59
suicide in Perth
15-39 year old Female Attempted
Attempted Suicide Admission Rate Per 10 000 Persons
9
35
Annual Consumption Per Adult Of Litres of Alcohol
15-39 year old Male Attempted Suicide Rate
25.
20'
15. A 0' 68
70
75
80
8
Year
Fig. 1. Attempted suicide admissions rates for 15-39-year-old males and females Statistical Division, with per adult (2 15 years) alcohol consumption, 1968-1984.
in the Perth
and females aged IS-39 years and over 40 years using population figures of the Australian Bureau of Statistics. Per adult (2 15 years) beer, wine, spirits, and absolute alcohol consumption figures for Western Australia were derived (Smith & Burvill, 1985). The alcohol consumption series stopped at 1984, as accurate beer consumption figures were not available for subsequent years. Mann-Whitney U tests (Siegel, 1956) were used to analyse the data, as it was not normally distributed. The attempted suicide rates for the 8 years with the highest per adult consumption for each beverage and total consumption were compared to the 8 years with the lowest consumption. For instance, for spirits, the 8 highest years were 1972-1973 to 1977-1978 and 1981-1982 to 1982-1983. In order to give the comparisons greater power, where appropriate, additional analyses were conducted comparing the 6 highest alcohol consumption years with the 6 lowest years. RESULTS
During the 8 years of highest wine consumption, the 15 to 39-year-old males had significantly higher rates of attempted suicide admissions than for the other years (Table 1). For spirits, the U value of 15 was insignificant @ = .082), but an analysis restricted to the 6 highest and 6 lowest years gave a significant result (U = 4, p = .026). When the wine and spirits data in Table 1 was combined to compare the 8 highest and lowest years, a
60
D. IAN SMITH and PETER W. BURVILL
significant result was obtained (U = 6, p = 0.004). Table 1 shows that the 15- to 39-year-old females also had their highest admission rates for attempted suicide during the years of high spirits consumption (U = 7, p = ,006). However, the wine result was insignificant. For the 8 highest and 8 lowest spirits consumption years in Table 1, the annual means were 1.65 and 1.40 L of alcohol per adult, respectively. This is a difference of 17.9%. The attempted suicide means for the same years for the 15- to 39-year-old males were 22.44 and 19.24, and for the 15- to 39-year-old females 40.32 and 32.13, respectively. The percentage difference for the males was 16.6% and 25.5% for the females. All the beer results in Table 1 were insignificant. Consistent with this, from Figure 1 it can be seen that the per adult beer consumption figures had no apparent relationship with the attempted suicide admission rates for the 15-39-year-olds. DISCUSSION
The prediction of higher alcohol content beverages being more likely to be related to attempted suicide admission rates than the lower alcohol content beverages was clearly supported as both the male and the female 15- to 39-year age groups had significant findings for spirits. None of the beer results were significant. The significant wine result in Table 1 is a little difficult to interpret. It could be a reflection that 4 of the highest wine consumption years were also 4 of the highest spirits consumption years. The effect of the additional wine consumption may have been to accentuate the effect of the high level of spirits consumption. Alternatively, the significant wine result may merit attention in its own right because of the alcohol content of wine being higher than that of beer. In seeking to understand the significant spirits results one has to bear in mind the possibility of a preselection factor in addition to the specific effect of a rapidly rising BAL (Gustafson & Kallmen, 1988; Wallgren & Barry, 1970). Perhaps those females with excessive personal problems, depression, frustration, or anger, who are the high-risk group for attempted suicide, are overrepresented among spirits drinkers. If this is correct, then the effect on emotions and control of drinking of a BAL increasing quickly would not be distributed throughout the general population, but rather concentrated on a relatively small number of people for whom it may act as a trigger for attempted suicide (James et al., 1963). An alternative way to gain some idea of the relationship between spirits consumption and the variation in attempted suicide morbidity rates in Perth is to compare the spirits consumption and attempted suicide rates for the years included in Table 1. The comparisons showed that for the 15- to 39-year-old males, the percentage change in the attempted suicide rates was approximately the same as for the percentage change in spirits consumption. By contrast, for the 15- to 39-year-old females, the percentage change in the attempted suicide rates was noticeably greater. A possible explanation is the increased alcohol consumption, especially of spirits (Australian Bureau of Statistics, 1984) by young females. In Western Australia, approximately two-thirds of all alcohol is consumed as beer. Consequently, the level of absolute alcohol consumption will be heavily influenced by changes in beer consumption, rather than wine or spirits, as can be seen from Figure 1. This explains why it was possible to obtain significant results for spirits, and to a lesser extent wine, yet absolute alcohol consumption was not related to the various attempted suicide morbidity rates. The insignificant results for the older persons in Table 1 are consistent with clinical experience in that with increasing age, persons are more likely to commit suicide rather than to attempt suicide (Weissman, 1974). Another possible explanation is that the admissions for “attempted suicide” of the older persons may be failed suicides. By contrast, the “attempted suicide” admissions for the younger males and females may be parasuicides. If correct, the
Alcohol consumption/attempted
61
suicide in Perth
circumstances that led to admissions by older persons for attempted suicide may be different to the factors contributing to the admissions for the same diagnosis by younger persons. For instance, with increasing age, alcohol consumption may be less important and depression more important. The results of this epidemiologic study indicate that the level of spirits consumption could have been a factor that influenced the number of attempted suicide admissions in Perth from 1968 to 1984 for 15- to 39-year-olds. To investigate further a possible spirits factor, it is suggested that in clinical studies of attempted suicide, researchers should ask what type of alcoholic beverage the patient (a) usually consumes and (b) consumed just prior to the attempted suicide, if applicable. If an overrepresentation of spirit drinkers was to be found in response to (b) in particular, this would be consistent with the above epidemiologic findings and have clinical significance. For instance, it would suggest that any patient with an attempted suicide history or who is judged as being at risk of attempting suicide (e.g., presenting with severe depression) should be asked if they consume alcohol and, if so, the type of beverage. If the patient was found to be a spirits drinker, there would appear to be merit in encouraging the patient to switch to a lower alcohol content beverage. Should clinical studies confirm the spirits-attempted suicide relationship, prevention of attempted suicide could also be enhanced by discouraging spirits consumption at a societal level. For instance, prevention initiatives (e.g., price iucreases) to reduce alcohol-related attempted suicide should in particular focus on spirits.
REFERENCES Australian Bureau of Statistics. (1984). Alcohol Consumption Patterns, South Australia, October 1983. Catalogue No. 4304.4. Gustafson, R., & Klllmen, H. (1988). The blood alcohol curve as a function of time and type of beverage: Methodological considerations. Drug and Alcohol Dependence, 21, 243-246. James, I.P., Scott-Orr, D.N., & Cumow, D.H. (1963). Blood alcohol levels following attempted suicide. Quarterly Journal Studies on Alcohol, 24, 14-22. Kendell, R.E. (1983). Alcohol and suicide. Subsrance and Alcohol AcrionslMisuse, 4, 121-127. Ritson, B. (1977). Alcoholism and suicide. In G. Edwards & M. Grant @is.), Alcoholism: New, knowledge and new responses (pp. 271-278). London: Croom Helm. Roizen, R. (1982). Estimating alcohol consumption in serious events. In National Institute on Alcohol Abuse and Alcoholism, Alcohol consumption and relatedproblems, Alcohol and health monograph No I (pp. 179-219). Washington, DC: U.S. Government Printing Office. Schuckit, M.A. (1986). Primary men alcoholics with histories of suicide attempts. Journal of.Srudies on Alcohol, 47, 78-81.
Siegel, S. (1956). Nonparametric srarisrics for the behavioral sciences. New York: McGraw-Hill. Smith, D.I. (1990). Alcohol and crime: The problem in Australia. Law, treatment and control. In R. Bluglass & P. Bowden (Eds.), Principles and practice of forensic psychiatry. London: Churchill Livingstone. Smith, D.I., & Burvill, P.W. (1985). Epidemiology of liver cirrhosis morbidity and mortality in Western Australia, 1971-82: Some preliminary findings. Drug and Alcohol Dependence, 15, 35-45. Wallgren, H., & Barry, H., III. (1970). Actions of alcohol: Vol. 2. chronic and clinical aspects. Amsterdam: Elsevier. Weissman, M.M. (1974). The epidemiology of suicide attempts, 1960 to 1971. Archives of General Psychiarry, 30, 737-746.
World Health Organisation. World Health Organisation.
(1967). Infernational (1977). International
ClasstQication of Diseases Classification of Diseases
(8th rev.). Geneva: (9th rev.). Geneva:
WHO. WHO.
Vol. 16, pp. 57-61, Printed in the USA. All rights reserved.
1991 Copyright
0306-4603191 $3.00 + .oO c 1991 Pergamon Press plc
BRIEF REPORT RELATIONSHIP BETWEEN ALCOHOL CONSUMPTION AND ATTEMPTED SUICIDE MORBIDITY RATES IN PERTH, WESTERN AUSTRALIA, 196th1984 D. IAN SMITH and PETER W. BURVILL University
of Western Australia
Abstract - Per adult (2 15 years) consumption of beer, wine, spirits, and absolute alcohol for a 17-year period (1968-1984) was related to the attempted suicide morbidity rates in the Perth urban area of Western Australia. For both males and females aged 15-39 years, Mann-Whitney U tests showed that during the years of highest spirits consumption, the highest rates for attempted suicide occurred. A similar finding also applied to 15-39-year-old males for wine. The effect of a rapidly rising blood alcohol level. together with a preselection factor as to the personal characteristics of persons who consumed the higher alcohol content drinks, may explain the results, which need to be confirmed by clinical studies of the typ of alcoholic beverage consumed by persons prior to attempting suicide.
Attempted suicide is by no means a homogeneous phenomenon. For instance, differences in rates between males and females, and between younger and older persons have been documented. Of relevance to this article, suicide attempters tend to be young, with a preponderance of females, who frequently display depression and make their attempt on impulse (Weissman, 1974). A number of studies have also shown that alcohol is a factor of some importance in the aetiology of attempted suicide. Roizen (1982) summarised the results of 17 surveys and found that 15-64% of the persons included in each study consumed alcohol prior to their suicide attempt. Similar findings were reported by Kendell (1983). From a clinical perspective, research has shown that those identified as being at risk for suicide attempts tend to be depressed, maladjusted, and have poor control over their often excessive drinking. In addition to its effect of impairing judgment, alcohol can give a person the courage to act on impulse and attempt suicide, and especially for persons with a history of alcohol-related problems (Ritson, 1977). Not surprisingly, therefore, among persons entering alcohol treatment programmes, the attempted suicide rate can be quite high (Schuckit, 1986). Of 50 attempted suicide patients admitted to Royal Perth Hospital in Western Australia, 28% had blood alcohol levels in excess of 0.15% (150 mg/lOO mL), while a further 34% had levels between 0.05% and 0.15% (James, Scott-Orr, & Cumow, 1963). The researchers commented that alcohol intoxication seemed to be the main factor in attempted suicide for some unstable persons, and to act as a trigger for a suicide attempt for others. Although liver cirrhosis is an alcohol-related problem that can take lo-15 years to develop, changes in the overall community level of alcohol consumption have been shown to quickly influence liver cirrhosis morbidity rates (Smith & Burvill, 1985). Similarly, the We wish to thank the Statistics Branch of the Health Department of Western Australia for supplying the morbidity data used for the study. Requests for reprints should be sent to D. Ian Smith, Ph.D., WA Alcohol and Drug Authority, 35 Havelock Street, West Perth, 6005 Australia. 57
D. IAN SMITH and PETER W. BURVILL
58
Table 1. Mann-Whitney U tests comparing attempted suicide morbidity rates in the Perth Statistical Division for the eight highest and eight lowest years of beer, wine, spirits, and absolute alcohol consumption from 1968 to 1984 Age-Sex Group Males 15-39 Males 40+ Females 15-39 Females 40+
Beer
Wine
21 32 36 34
10* 32 38 48
Spirits 15 26 1** 22
Absolute Alcohol 18 37 39 42
Two-tail tests were used. *p < 0.05. **p c: 0.01.
more alcohol a community consumes, the greater is the likelihood that people will have access to alcohol at times of suicidal impulses. Consequently, it can be predicted that there should be a positive relationship between the level of alcohol consumption in a community, and the rate of attempted suicide. If so, this would have important implications for prevention initiatives, for it would suggest that by reducing overall alcohol consumption the rate of attempted suicide could be reduced (Kendell, 1983). Wallgren and Barry (1970) stated that many of the effects of alcohol depend not only on the concentration achieved, but also on the rate of rise of the concentration. For instance, reports of more violent intoxication after consuming equal quantities of alcohol as spirits rather than as beer are consistent with the effect of a rapid rise in the blood alcohol level (BAL), as demonstrated by Gustafson and Klllmen (1988). This raises the possibility that if a person’s BAL is rapidly rising, the likelihood of the person attempting suicide may be greater than for a slowly rising BAL, and in particular because of the greater distortion of judgment, mood, and emotions of drinkers. If correct, the hypothesis that follows is that the higher the alcohol content of a beverage, the more likely it is to be related to attempted suicide. Support for this prediction comes from a previous study (Smith, 1990) that found that spirits consumption was closely related to the rates of (a) charges for homicide and (b) emergency hospital admissions caused by injury purposely inflicted by other persons. The aim of this study was to investigate the relationship between attempted suicide rates and alcohol consumption in the community. and in particular to test the hypothesis that the higher the alcohol content of a beverage. the more closely should that beverage be related to variations in the attempted suicide rates. METHOD
In Western Australia, virtually all admissions for attempted suicide are made to general hospitals, whether they are public or private hospitals. By contrast, many of the admissions to mental health hospitals for attempted suicide are, in effect, discharges from general hospitals. Consequently, the data base for the study was restricted to general hospital admissions for attempted suicide coded E950-958 (WHO, 1967, 1977) during the period 1968-1984. Admissions caused by the late effects of self-inflicted injury (E959) were omitted from the study. The Ninth Revision of the International Classification of Diseases (WHO, 1977) was used to code admissions after January 1, 1979. The study was restricted to admissions in the Perth Statistical Division, the capital city urban area of Western Australia. Attempted suicide morbidity rates were calculated for males
Alcohol consumption/attempted
59
suicide in Perth
15-39 year old Female Attempted
Attempted Suicide Admission Rate Per 10 000 Persons
9
35
Annual Consumption Per Adult Of Litres of Alcohol
15-39 year old Male Attempted Suicide Rate
25.
20'
15. A 0' 68
70
75
80
8
Year
Fig. 1. Attempted suicide admissions rates for 15-39-year-old males and females Statistical Division, with per adult (2 15 years) alcohol consumption, 1968-1984.
in the Perth
and females aged IS-39 years and over 40 years using population figures of the Australian Bureau of Statistics. Per adult (2 15 years) beer, wine, spirits, and absolute alcohol consumption figures for Western Australia were derived (Smith & Burvill, 1985). The alcohol consumption series stopped at 1984, as accurate beer consumption figures were not available for subsequent years. Mann-Whitney U tests (Siegel, 1956) were used to analyse the data, as it was not normally distributed. The attempted suicide rates for the 8 years with the highest per adult consumption for each beverage and total consumption were compared to the 8 years with the lowest consumption. For instance, for spirits, the 8 highest years were 1972-1973 to 1977-1978 and 1981-1982 to 1982-1983. In order to give the comparisons greater power, where appropriate, additional analyses were conducted comparing the 6 highest alcohol consumption years with the 6 lowest years. RESULTS
During the 8 years of highest wine consumption, the 15 to 39-year-old males had significantly higher rates of attempted suicide admissions than for the other years (Table 1). For spirits, the U value of 15 was insignificant @ = .082), but an analysis restricted to the 6 highest and 6 lowest years gave a significant result (U = 4, p = .026). When the wine and spirits data in Table 1 was combined to compare the 8 highest and lowest years, a
60
D. IAN SMITH and PETER W. BURVILL
significant result was obtained (U = 6, p = 0.004). Table 1 shows that the 15- to 39-year-old females also had their highest admission rates for attempted suicide during the years of high spirits consumption (U = 7, p = ,006). However, the wine result was insignificant. For the 8 highest and 8 lowest spirits consumption years in Table 1, the annual means were 1.65 and 1.40 L of alcohol per adult, respectively. This is a difference of 17.9%. The attempted suicide means for the same years for the 15- to 39-year-old males were 22.44 and 19.24, and for the 15- to 39-year-old females 40.32 and 32.13, respectively. The percentage difference for the males was 16.6% and 25.5% for the females. All the beer results in Table 1 were insignificant. Consistent with this, from Figure 1 it can be seen that the per adult beer consumption figures had no apparent relationship with the attempted suicide admission rates for the 15-39-year-olds. DISCUSSION
The prediction of higher alcohol content beverages being more likely to be related to attempted suicide admission rates than the lower alcohol content beverages was clearly supported as both the male and the female 15- to 39-year age groups had significant findings for spirits. None of the beer results were significant. The significant wine result in Table 1 is a little difficult to interpret. It could be a reflection that 4 of the highest wine consumption years were also 4 of the highest spirits consumption years. The effect of the additional wine consumption may have been to accentuate the effect of the high level of spirits consumption. Alternatively, the significant wine result may merit attention in its own right because of the alcohol content of wine being higher than that of beer. In seeking to understand the significant spirits results one has to bear in mind the possibility of a preselection factor in addition to the specific effect of a rapidly rising BAL (Gustafson & Kallmen, 1988; Wallgren & Barry, 1970). Perhaps those females with excessive personal problems, depression, frustration, or anger, who are the high-risk group for attempted suicide, are overrepresented among spirits drinkers. If this is correct, then the effect on emotions and control of drinking of a BAL increasing quickly would not be distributed throughout the general population, but rather concentrated on a relatively small number of people for whom it may act as a trigger for attempted suicide (James et al., 1963). An alternative way to gain some idea of the relationship between spirits consumption and the variation in attempted suicide morbidity rates in Perth is to compare the spirits consumption and attempted suicide rates for the years included in Table 1. The comparisons showed that for the 15- to 39-year-old males, the percentage change in the attempted suicide rates was approximately the same as for the percentage change in spirits consumption. By contrast, for the 15- to 39-year-old females, the percentage change in the attempted suicide rates was noticeably greater. A possible explanation is the increased alcohol consumption, especially of spirits (Australian Bureau of Statistics, 1984) by young females. In Western Australia, approximately two-thirds of all alcohol is consumed as beer. Consequently, the level of absolute alcohol consumption will be heavily influenced by changes in beer consumption, rather than wine or spirits, as can be seen from Figure 1. This explains why it was possible to obtain significant results for spirits, and to a lesser extent wine, yet absolute alcohol consumption was not related to the various attempted suicide morbidity rates. The insignificant results for the older persons in Table 1 are consistent with clinical experience in that with increasing age, persons are more likely to commit suicide rather than to attempt suicide (Weissman, 1974). Another possible explanation is that the admissions for “attempted suicide” of the older persons may be failed suicides. By contrast, the “attempted suicide” admissions for the younger males and females may be parasuicides. If correct, the
Alcohol consumption/attempted
61
suicide in Perth
circumstances that led to admissions by older persons for attempted suicide may be different to the factors contributing to the admissions for the same diagnosis by younger persons. For instance, with increasing age, alcohol consumption may be less important and depression more important. The results of this epidemiologic study indicate that the level of spirits consumption could have been a factor that influenced the number of attempted suicide admissions in Perth from 1968 to 1984 for 15- to 39-year-olds. To investigate further a possible spirits factor, it is suggested that in clinical studies of attempted suicide, researchers should ask what type of alcoholic beverage the patient (a) usually consumes and (b) consumed just prior to the attempted suicide, if applicable. If an overrepresentation of spirit drinkers was to be found in response to (b) in particular, this would be consistent with the above epidemiologic findings and have clinical significance. For instance, it would suggest that any patient with an attempted suicide history or who is judged as being at risk of attempting suicide (e.g., presenting with severe depression) should be asked if they consume alcohol and, if so, the type of beverage. If the patient was found to be a spirits drinker, there would appear to be merit in encouraging the patient to switch to a lower alcohol content beverage. Should clinical studies confirm the spirits-attempted suicide relationship, prevention of attempted suicide could also be enhanced by discouraging spirits consumption at a societal level. For instance, prevention initiatives (e.g., price iucreases) to reduce alcohol-related attempted suicide should in particular focus on spirits.
REFERENCES Australian Bureau of Statistics. (1984). Alcohol Consumption Patterns, South Australia, October 1983. Catalogue No. 4304.4. Gustafson, R., & Klllmen, H. (1988). The blood alcohol curve as a function of time and type of beverage: Methodological considerations. Drug and Alcohol Dependence, 21, 243-246. James, I.P., Scott-Orr, D.N., & Cumow, D.H. (1963). Blood alcohol levels following attempted suicide. Quarterly Journal Studies on Alcohol, 24, 14-22. Kendell, R.E. (1983). Alcohol and suicide. Subsrance and Alcohol AcrionslMisuse, 4, 121-127. Ritson, B. (1977). Alcoholism and suicide. In G. Edwards & M. Grant @is.), Alcoholism: New, knowledge and new responses (pp. 271-278). London: Croom Helm. Roizen, R. (1982). Estimating alcohol consumption in serious events. In National Institute on Alcohol Abuse and Alcoholism, Alcohol consumption and relatedproblems, Alcohol and health monograph No I (pp. 179-219). Washington, DC: U.S. Government Printing Office. Schuckit, M.A. (1986). Primary men alcoholics with histories of suicide attempts. Journal of.Srudies on Alcohol, 47, 78-81.
Siegel, S. (1956). Nonparametric srarisrics for the behavioral sciences. New York: McGraw-Hill. Smith, D.I. (1990). Alcohol and crime: The problem in Australia. Law, treatment and control. In R. Bluglass & P. Bowden (Eds.), Principles and practice of forensic psychiatry. London: Churchill Livingstone. Smith, D.I., & Burvill, P.W. (1985). Epidemiology of liver cirrhosis morbidity and mortality in Western Australia, 1971-82: Some preliminary findings. Drug and Alcohol Dependence, 15, 35-45. Wallgren, H., & Barry, H., III. (1970). Actions of alcohol: Vol. 2. chronic and clinical aspects. Amsterdam: Elsevier. Weissman, M.M. (1974). The epidemiology of suicide attempts, 1960 to 1971. Archives of General Psychiarry, 30, 737-746.
World Health Organisation. World Health Organisation.
(1967). Infernational (1977). International
ClasstQication of Diseases Classification of Diseases
(8th rev.). Geneva: (9th rev.). Geneva:
WHO. WHO.