Substance Abuse Increases Suicide Risk

Suicides are not random; each occurs in a particular context. The association between specific psychiatric syndromes—such as Depression or abuse of alcohol or drugs—and suicidal behavior has been studied by epidemiologists using both retrospective and prospective methods. Since interviews with suicide completers are impossible, retrospective reviews of the circumstances predating suicides have been conducted. By using interviews of relatives and others familiar with the suicide victim, together with study of medical records, suicide notes, and coroner reports, each suicide case is subjected to a ''psychologic autopsy.'' Factors that distinguish successful suicide cases from suicide attempters and substance abusers who have never attempted suicide are compared in the hope that differences in these factors may identify those at particular risk of attempted or completed suicide. A limitation of retrospective studies is termed recall bias: informants may provide information about the suicide victim that is distorted by their attempt to explain the suicide event. Although written records and use of standardized methods to collect diagnostic information can reduce this bias, prospective studies are more reliable. Prospective studies in the general population are not feasible, because suicide is rare, occurring in only about 1 in 10,000 annually; however, about 10 percent of suicide attempters, 15 percent of depressed people, and 3 percent of alcoholics eventually commit suicide. By prospective study of such high-risk groups, additional risk factors can be identified during a follow-up period.

Although most heavy drinkers are not alcoholic, heavy drinking in young adulthood is associated with suicide in middle adulthood. A prospective study of Swedish military conscripts found that those who drank more than twenty drinks weekly had three times the death rate, prior to age forty, of light drinkers. Most of these premature deaths were due to suicide or accidents. Those who develop alcohol dependence or abuse are, together with drug abusers, at increased risk of death from accidents, liver disease, pancreatitis, respiratory disease, and other illnesses; however, suicide is among the most significant causes of death in both male and female substance abusers. U.S. and Swedish prospective studies, for example, found that alcoholism increased the risk of suicide fourfold in men and twentyfold in women.

Next to depression, alcoholism and drug abuse are the psychiatric conditions most strongly associated with suicide attempts. In the U.S. Epidemiologic Catchment Area (ECA) Study conducted in the 1980s, the risk of suicide attempts was increased forty-onefold by depression and eighteenfold by alcoholism. While Cocaine users had increased rates of suicide attempts, users of Marijuana, Sedative-Hypnotics, and Amphetamines did not.

Among completed suicides, the proportion who were alcoholics or drug abusers is large: Prior to 1980, Alcoholism accounted for about 20 to 35 percent, and drug abuse for less than 5 percent, of suicides in a variety of countries. In the San Diego Suicide Study, conducted in the early 1980s, well over 50 percent of 274 consecutive suicides had alcoholism or drug abuse or dependence. Much of the increase in young-adult suicide rates since the 1960s is attributable to alcoholism and drug abuse or dependence.

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