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Substance use and suicidal behaviour
Special populations
Substance use and suicidal behaviour
This contribution discusses the relationship of substance abuse with suicide and self-harm. Alcohol has long been recognized as a major contributor to suicide and, as the abuse of other substances has risen, there is now increasing evidence of their contribution to suicidal behaviour and suicide.5
Rachel Jenkins
Contribution of substance abuse to suicide Psychological autopsy studies show that while psychiatric illness is the central antecedent in 90–100% of cases of completed suicide, alcoholism or other substance abuse is found in 20–50% of cases; it is thus second only to depressive disorder as a psychi atric contributor to suicide.5 Indeed, it is when substance abuse is comorbid with affective disorder that it contributes most to suicide. Nearly all diagnosed cases of personality disorder identified retrospectively in suicides are complicated by substance abuse.6
Abstract Suicide and self-harm are receiving increased attention and awareness from policymakers, professionals, researchers and the public. Globally, suicide is thought to be the 15th leading cause of death, although this may be an underestimate because it does not take into account – ‘unofficial’ suicides (deaths that are suicides but not recorded as such, i.e. open verdicts), and many countries do not yet have vital registration systems. Self-harm is not recorded nationally, although there are a number of good studies within and between countries. This contribution discusses the relationship of substance abuse with suicide and self-harm. Alcohol has long been recognized as a major contributor to suicide and, as the abuse of other substances has risen, there is now increasing evidence of their contribution to suicidal behaviour and suicide. Thus, substance abuse is the second most frequent precursor to suicide after depressive illness. The negative consequences of substance abuse accumulate in a vicious circle of diminishing social support and increased exposure to life events, subsequent affective disorder and increased suicidal risk. Help is infrequently sought and poorly used. Health and social care professionals need to be aware that depression and substance abuse form a lethal combination, and that vigorous treatment of comorbid depression is the most promising avenue for prevention of suicide in people with substance abuse.
Lifetime risk of suicide in alcohol abuse It used to be thought that the lifetime risk of suicide in alcoholics was 15%,7 but subsequent longitudinal studies have shown that the lifetime risk is much lower and is influenced by both individual clinical status and the contextual national suicide rate. For countries with historically low and intermediate suicide rates (e.g. low: Norway, Scotland, Trinidad; intermediate: USA, Canada, England and Wales) (Table 1), the lifetime risk of suicide in alcoholics is between 2.5% and 3.5%, depending on clinical status; this risk is nearly doubled in countries with relatively high suicide rates (e.g. Sweden, Austria, Germany).8,9 Sex differences: women generally have lower suicide rates than men, except in some countries in the West Pacific region and Southeast Asia; they also have lower rates of substance abuse. The proportion of suicides attributable to substance abuse is accordingly lower. In the ten published psychological autopsy studies providing data by sex, nearly one-third of male suicides are identified as ‘alcoholics’, compared with only 1 in 7 female suicides.5
Keywords alcohol; life events; self-harm; social support; substance abuse; suicidal risk; suicide
Role of social factors
Suicide and self-harm are receiving increased attention and awareness from policymakers, professionals, researchers and the public.1,2 Globally, suicide is thought to be the 15th leading cause of death,3 although this may be an underestimate because it does not take into account ‘unofficial’ suicides (deaths that are suicides but not recorded as such, i.e. open verdicts), and many countries do not yet have vital registration systems.4 Self-harm is not recorded nationally, although there are a number of good studies within and between countries.
Stressful life events are key contributors to suicide, especially in people with substance abuse,10 and social support is a protective factor in suicide. The UK Office for National Statistics survey showed that stressful life events are more common and social support is more restricted in people who abuse alcohol and in people who abuse drugs than in the general population.11
Contribution of substance abuse to suicidal thoughts and to suicide attempts Substance abuse substantially increases the risk of suicidal thoughts. For example, in the second British Psychiatric Morbidity Survey,12 35% of men with moderate or severe alcohol dependence had suicidal thoughts in the last year and 10% had made an actual attempt in the last year, compared with 3% and 0.3% respectively of men with no alcohol dependence. There were too few women in the survey with moderate or severe dependence to present figures, but even mild alcohol dependence in women
Rachel Jenkins FRCPsych FFOHM Dist. FAPA is Director of the WHO Collaborating Centre at the Institute of Psychiatry, London, UK, and Visiting Professor. She is a psychiatrist and epidemiologist, and collaborates with international organizations to give mental health policy and research support to low-income countries. She is currently on secondment from the Department of Health, where she was principal medical officer for mental health from 1987 to 1996. Conflicts of interest: none declared.
PSYCHIATRY 6:1
16
Published by Elsevier Ltd.
Special populations
of suicide attempts (odds ratio 27.1) and of completed suicide (odds ratio 2.4). Hawton et al. found that in a series of selfharm patients in Oxford, UK, 12% of males and 6% of females were drug users. They also found that substance-abusing suicide attempters had a particularly high rate of repetition of suicide attempts.14 Substance abuse was the key diagnostic predictor of eventual suicide.15
Characteristics of 4859 suicides in contact with mental health services in England and Wales
Sociodemographic characteristics Median age (range) Male Ethnic minority Not currently married Unemployed/long-term sick Living alone Clinical characteristics Any secondary diagnosis Over 5 previous admissions History of previous self-harm History of violence History of alcohol misuse History of drug misuse Aspects of clinical care Last contact with services within 7 days Symptoms at last contact Out of contact with services Non-compliant with treatment
Number (n = 4859)
% (95% CI)
41 yrs (13–95 yrs) 3198 282 3405 2765 2006
66 6 71 58 43
2460 712
52 (51–54) 16 (15–17)
3077
64 (63–66)
920 1899 1348
19 (18–21) 40 (38–41) 28 (27–30)
2308
48 (47–50)
2990 1153
64 (63–65) 9 (27–30)
929
22 (21–24)
Prevention of suicide in people with substance abuse
(64–67) (5–7) (70–73) (58–60) (41–44)
Clinical monitoring of the known psychosocial risk factors for suicide in people with substance abuse is important. Murphy found in a retrospective series of suicides in people with severe alcohol abuse that more than four-fifths had communicated suicidal thoughts, verbally or behaviourally, or both, and 38% had made a previous attempt. Two-thirds had little or no social support, half were unemployed and half had significant medical problems. Nearly two-fifths were living alone. Murphy argues that with nine out of ten ‘alcoholic’ suicides having at least three of these factors, close monitoring of these factors may help in the assessment of the changing suicidal risk in alcoholics.10 Treatment Treatment of the substance abuse would be very helpful but remains difficult. However, effective treatments exist for the comorbid depression,16 which should be treated vigorously. Ready access to means of suicide should be restricted (e.g. by restricting pack sizes of paracetamol).
Conclusion Substance abuse is the second most frequent precursor to suicide after depressive illness. The negative consequences of substance abuse accumulate in a vicious circle of diminishing social support and increased exposure to life events, subsequent affective disorder and increased suicidal risk. Help is infrequently sought and poorly used. Health and social care professionals need to be aware that depression and substance abuse form a lethal combination, and that vigorous treatment of comorbid depression is the most promising avenue for prevention of suicide in people with substance abuse. ◆
Source: Department of Health, 2001.
Table 1
increased the risk of suicidal thoughts to 12.5% and suicidal attempts 3.4% in the last year, compared with 3.8% and 0.4% respectively of women with no alcohol dependence. Similarly, 12% of men with cannabis dependence had suicidal thoughts in the last year, and 0.4% had made an actual suicide attempt, compared with 3% and 0.5% respectively of men with no cannabis abuse. Eighteen percent of women with cannabis dependence had suicidal thoughts in the last year and 4% had made an actual attempt, compared with 4% and 0.5% respectively of women with no cannabis dependence. In a similar large national psychiatric morbidity survey of British prisoners, of those with suicidal thoughts in the last year, 37% had an AUDIT score of over 16, and 49% were dependent on stimulants or opiates or both. Of those who made suicidal attempts in the last year, again 40% had an AUDIT score of over 16, and 50% were dependent on stimulants or opiates or both. Of prisoners with suicidal attempts in last week, the relationship with substance abuse was even more marked, with 55% having an AUDIT score of over 16, while 64% were dependent on opiates or stimulants. Suicide attempters were twice as likely to be heavy smokers as those who had never attempted suicide.13 A 25-year prospective study of Swedish male conscripts showed that those who abused alcohol had a highly elevated risk
PSYCHIATRY 6:1
References 1 Jenkins R, Singh B. General population strategies for suicide prevention. In: Hawton K, van Heeringen K, eds. The international handbook of suicide and attempted suicide. Chichester: Wiley, 2000. 2 Hawton K, van Heeringen K, eds. The international handbook of suicide and attempted suicide. Chichester: Wiley, 2000. 3 World Health Organization. World health report. Geneva: WHO, 2000. 4 Jenkins R. Addressing suicide as a public-health problem. Lancet 2002; 359: 813–14. 5 Murphy GE. Psychiatric aspects of suicidal behaviour: substance abuse. In: Hawton K, van Heeringen K, eds. The international handbook of suicide and attempted suicide. Chichester: Wiley, 2000. 6 Cheng AT, Mann AH, Chan KA. Personality disorder and suicide. A case-control study. Br J Psychiatry 1997; 170: 441–46.
17
Published by Elsevier Ltd.
Special populations
7 Miles CP. Conditions predisposing to suicide: a review. J Nerv Ment Dis 1977; 164: 231–46. 8 Murphy GE, Wetzel RD. The lifetime risk of suicide in alcoholism. Arch Gen Psychiatry 1990; 47: 383–92. 9 Rossow I, Amundsen A. Alcohol abuse and suicide: a 40-year prospective study of Norwegian conscripts. Addiction 1995; 90: 685–91. 10 Murphy GE. Suicide in alcoholism. New York: Oxford University Press, 1992. 11 Coulthard M, Farrell M, Singleton N, Meltzer H. Tobacco, alcohol and drug use and mental health. London: Stationery Office, 2002. 12 Meltzer H, Lader D, Corbin T, Singleton N, Jenkins R, Brugha T. Non-fatal suicidal behaviour among adults aged 16 to 74 in Great Britain. London: Stationery Office, 2002. 13 Jenkins R, Bhugra D, Meltzer H, et al. Psychiatric and social aspects of suicidal behaviour in prisons. Psychol Med 2005; 35: 257–69. 14 Hawton K, Sinton S, Fagg J. Deliberate self-harm in alcohol and substance misuse: patient characterstics and patterns of clinical care. Drug Alcohol Rev 1997; 16: 123–29.
PSYCHIATRY 6:1
15 Hawton K, Fagg J, Platt S, Hawkins M. Factors associated with suicide after parasuicide in young people. Br Med J 1993; 306: 1641–44. 16 Mason BJ, Kocsis JH. Desipramine treatment of alcoholism. Psychopharmacol Bull 1991; 27: 155–61.
Further reading Department of Health. National suicide prevention strategy for England. London: Stationery Office, 2001. Farrell M, Howes S, Taylor C, et al. Substance misuse and psychiatric morbidity: an overview of the OPCS National Psychiatric Morbidity Survey. Addict Behav 1998; 23: 909–18. World Health Organization Collaborating Centre for Research and Training for Mental Health. WHO guide to mental health in primary care. London: Royal Society of Medicine Press, 2000.
18
Published by Elsevier Ltd.
Substance use and suicidal behaviour
This contribution discusses the relationship of substance abuse with suicide and self-harm. Alcohol has long been recognized as a major contributor to suicide and, as the abuse of other substances has risen, there is now increasing evidence of their contribution to suicidal behaviour and suicide.5
Rachel Jenkins
Contribution of substance abuse to suicide Psychological autopsy studies show that while psychiatric illness is the central antecedent in 90–100% of cases of completed suicide, alcoholism or other substance abuse is found in 20–50% of cases; it is thus second only to depressive disorder as a psychi atric contributor to suicide.5 Indeed, it is when substance abuse is comorbid with affective disorder that it contributes most to suicide. Nearly all diagnosed cases of personality disorder identified retrospectively in suicides are complicated by substance abuse.6
Abstract Suicide and self-harm are receiving increased attention and awareness from policymakers, professionals, researchers and the public. Globally, suicide is thought to be the 15th leading cause of death, although this may be an underestimate because it does not take into account – ‘unofficial’ suicides (deaths that are suicides but not recorded as such, i.e. open verdicts), and many countries do not yet have vital registration systems. Self-harm is not recorded nationally, although there are a number of good studies within and between countries. This contribution discusses the relationship of substance abuse with suicide and self-harm. Alcohol has long been recognized as a major contributor to suicide and, as the abuse of other substances has risen, there is now increasing evidence of their contribution to suicidal behaviour and suicide. Thus, substance abuse is the second most frequent precursor to suicide after depressive illness. The negative consequences of substance abuse accumulate in a vicious circle of diminishing social support and increased exposure to life events, subsequent affective disorder and increased suicidal risk. Help is infrequently sought and poorly used. Health and social care professionals need to be aware that depression and substance abuse form a lethal combination, and that vigorous treatment of comorbid depression is the most promising avenue for prevention of suicide in people with substance abuse.
Lifetime risk of suicide in alcohol abuse It used to be thought that the lifetime risk of suicide in alcoholics was 15%,7 but subsequent longitudinal studies have shown that the lifetime risk is much lower and is influenced by both individual clinical status and the contextual national suicide rate. For countries with historically low and intermediate suicide rates (e.g. low: Norway, Scotland, Trinidad; intermediate: USA, Canada, England and Wales) (Table 1), the lifetime risk of suicide in alcoholics is between 2.5% and 3.5%, depending on clinical status; this risk is nearly doubled in countries with relatively high suicide rates (e.g. Sweden, Austria, Germany).8,9 Sex differences: women generally have lower suicide rates than men, except in some countries in the West Pacific region and Southeast Asia; they also have lower rates of substance abuse. The proportion of suicides attributable to substance abuse is accordingly lower. In the ten published psychological autopsy studies providing data by sex, nearly one-third of male suicides are identified as ‘alcoholics’, compared with only 1 in 7 female suicides.5
Keywords alcohol; life events; self-harm; social support; substance abuse; suicidal risk; suicide
Role of social factors
Suicide and self-harm are receiving increased attention and awareness from policymakers, professionals, researchers and the public.1,2 Globally, suicide is thought to be the 15th leading cause of death,3 although this may be an underestimate because it does not take into account ‘unofficial’ suicides (deaths that are suicides but not recorded as such, i.e. open verdicts), and many countries do not yet have vital registration systems.4 Self-harm is not recorded nationally, although there are a number of good studies within and between countries.
Stressful life events are key contributors to suicide, especially in people with substance abuse,10 and social support is a protective factor in suicide. The UK Office for National Statistics survey showed that stressful life events are more common and social support is more restricted in people who abuse alcohol and in people who abuse drugs than in the general population.11
Contribution of substance abuse to suicidal thoughts and to suicide attempts Substance abuse substantially increases the risk of suicidal thoughts. For example, in the second British Psychiatric Morbidity Survey,12 35% of men with moderate or severe alcohol dependence had suicidal thoughts in the last year and 10% had made an actual attempt in the last year, compared with 3% and 0.3% respectively of men with no alcohol dependence. There were too few women in the survey with moderate or severe dependence to present figures, but even mild alcohol dependence in women
Rachel Jenkins FRCPsych FFOHM Dist. FAPA is Director of the WHO Collaborating Centre at the Institute of Psychiatry, London, UK, and Visiting Professor. She is a psychiatrist and epidemiologist, and collaborates with international organizations to give mental health policy and research support to low-income countries. She is currently on secondment from the Department of Health, where she was principal medical officer for mental health from 1987 to 1996. Conflicts of interest: none declared.
PSYCHIATRY 6:1
16
Published by Elsevier Ltd.
Special populations
of suicide attempts (odds ratio 27.1) and of completed suicide (odds ratio 2.4). Hawton et al. found that in a series of selfharm patients in Oxford, UK, 12% of males and 6% of females were drug users. They also found that substance-abusing suicide attempters had a particularly high rate of repetition of suicide attempts.14 Substance abuse was the key diagnostic predictor of eventual suicide.15
Characteristics of 4859 suicides in contact with mental health services in England and Wales
Sociodemographic characteristics Median age (range) Male Ethnic minority Not currently married Unemployed/long-term sick Living alone Clinical characteristics Any secondary diagnosis Over 5 previous admissions History of previous self-harm History of violence History of alcohol misuse History of drug misuse Aspects of clinical care Last contact with services within 7 days Symptoms at last contact Out of contact with services Non-compliant with treatment
Number (n = 4859)
% (95% CI)
41 yrs (13–95 yrs) 3198 282 3405 2765 2006
66 6 71 58 43
2460 712
52 (51–54) 16 (15–17)
3077
64 (63–66)
920 1899 1348
19 (18–21) 40 (38–41) 28 (27–30)
2308
48 (47–50)
2990 1153
64 (63–65) 9 (27–30)
929
22 (21–24)
Prevention of suicide in people with substance abuse
(64–67) (5–7) (70–73) (58–60) (41–44)
Clinical monitoring of the known psychosocial risk factors for suicide in people with substance abuse is important. Murphy found in a retrospective series of suicides in people with severe alcohol abuse that more than four-fifths had communicated suicidal thoughts, verbally or behaviourally, or both, and 38% had made a previous attempt. Two-thirds had little or no social support, half were unemployed and half had significant medical problems. Nearly two-fifths were living alone. Murphy argues that with nine out of ten ‘alcoholic’ suicides having at least three of these factors, close monitoring of these factors may help in the assessment of the changing suicidal risk in alcoholics.10 Treatment Treatment of the substance abuse would be very helpful but remains difficult. However, effective treatments exist for the comorbid depression,16 which should be treated vigorously. Ready access to means of suicide should be restricted (e.g. by restricting pack sizes of paracetamol).
Conclusion Substance abuse is the second most frequent precursor to suicide after depressive illness. The negative consequences of substance abuse accumulate in a vicious circle of diminishing social support and increased exposure to life events, subsequent affective disorder and increased suicidal risk. Help is infrequently sought and poorly used. Health and social care professionals need to be aware that depression and substance abuse form a lethal combination, and that vigorous treatment of comorbid depression is the most promising avenue for prevention of suicide in people with substance abuse. ◆
Source: Department of Health, 2001.
Table 1
increased the risk of suicidal thoughts to 12.5% and suicidal attempts 3.4% in the last year, compared with 3.8% and 0.4% respectively of women with no alcohol dependence. Similarly, 12% of men with cannabis dependence had suicidal thoughts in the last year, and 0.4% had made an actual suicide attempt, compared with 3% and 0.5% respectively of men with no cannabis abuse. Eighteen percent of women with cannabis dependence had suicidal thoughts in the last year and 4% had made an actual attempt, compared with 4% and 0.5% respectively of women with no cannabis dependence. In a similar large national psychiatric morbidity survey of British prisoners, of those with suicidal thoughts in the last year, 37% had an AUDIT score of over 16, and 49% were dependent on stimulants or opiates or both. Of those who made suicidal attempts in the last year, again 40% had an AUDIT score of over 16, and 50% were dependent on stimulants or opiates or both. Of prisoners with suicidal attempts in last week, the relationship with substance abuse was even more marked, with 55% having an AUDIT score of over 16, while 64% were dependent on opiates or stimulants. Suicide attempters were twice as likely to be heavy smokers as those who had never attempted suicide.13 A 25-year prospective study of Swedish male conscripts showed that those who abused alcohol had a highly elevated risk
PSYCHIATRY 6:1
References 1 Jenkins R, Singh B. General population strategies for suicide prevention. In: Hawton K, van Heeringen K, eds. The international handbook of suicide and attempted suicide. Chichester: Wiley, 2000. 2 Hawton K, van Heeringen K, eds. The international handbook of suicide and attempted suicide. Chichester: Wiley, 2000. 3 World Health Organization. World health report. Geneva: WHO, 2000. 4 Jenkins R. Addressing suicide as a public-health problem. Lancet 2002; 359: 813–14. 5 Murphy GE. Psychiatric aspects of suicidal behaviour: substance abuse. In: Hawton K, van Heeringen K, eds. The international handbook of suicide and attempted suicide. Chichester: Wiley, 2000. 6 Cheng AT, Mann AH, Chan KA. Personality disorder and suicide. A case-control study. Br J Psychiatry 1997; 170: 441–46.
17
Published by Elsevier Ltd.
Special populations
7 Miles CP. Conditions predisposing to suicide: a review. J Nerv Ment Dis 1977; 164: 231–46. 8 Murphy GE, Wetzel RD. The lifetime risk of suicide in alcoholism. Arch Gen Psychiatry 1990; 47: 383–92. 9 Rossow I, Amundsen A. Alcohol abuse and suicide: a 40-year prospective study of Norwegian conscripts. Addiction 1995; 90: 685–91. 10 Murphy GE. Suicide in alcoholism. New York: Oxford University Press, 1992. 11 Coulthard M, Farrell M, Singleton N, Meltzer H. Tobacco, alcohol and drug use and mental health. London: Stationery Office, 2002. 12 Meltzer H, Lader D, Corbin T, Singleton N, Jenkins R, Brugha T. Non-fatal suicidal behaviour among adults aged 16 to 74 in Great Britain. London: Stationery Office, 2002. 13 Jenkins R, Bhugra D, Meltzer H, et al. Psychiatric and social aspects of suicidal behaviour in prisons. Psychol Med 2005; 35: 257–69. 14 Hawton K, Sinton S, Fagg J. Deliberate self-harm in alcohol and substance misuse: patient characterstics and patterns of clinical care. Drug Alcohol Rev 1997; 16: 123–29.
PSYCHIATRY 6:1
15 Hawton K, Fagg J, Platt S, Hawkins M. Factors associated with suicide after parasuicide in young people. Br Med J 1993; 306: 1641–44. 16 Mason BJ, Kocsis JH. Desipramine treatment of alcoholism. Psychopharmacol Bull 1991; 27: 155–61.
Further reading Department of Health. National suicide prevention strategy for England. London: Stationery Office, 2001. Farrell M, Howes S, Taylor C, et al. Substance misuse and psychiatric morbidity: an overview of the OPCS National Psychiatric Morbidity Survey. Addict Behav 1998; 23: 909–18. World Health Organization Collaborating Centre for Research and Training for Mental Health. WHO guide to mental health in primary care. London: Royal Society of Medicine Press, 2000.
18
Published by Elsevier Ltd.