|Year : 2019 | Volume
| Issue : 2 | Page : 195-200
Alcohol dependence syndrome in suicide attempters: A cross-sectional study in a rural tertiary hospital
P Sreelatha1, G Haritha1, V S. S R. Ryali1, Ryali P Janakiraman2
1 Department of Psychiatry, PES Institute of Medical Sciences and Research, Kuppam, Andhra Pradesh, India
2 Department of Community Medicine, PES Institute of Medical Sciences and Research, Kuppam, Andhra Pradesh, India
|Date of Submission||04-Jul-2019|
|Date of Decision||19-Jul-2019|
|Date of Acceptance||24-Jul-2019|
|Date of Web Publication||16-Dec-2019|
Dr. V S. S R. Ryali
Department of Psychiatry, PES Institute of Medical Sciences and Research, Chittoor, Kuppam - 517 425, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Background: Suicidal attempt is a phenomenon with a tremendous impact on the medical and social well-being of the individual, and alcohol abuse/dependence has consistently been implicated in the triggering of suicidal attempt. This complex interaction of alcohol and suicide needs further exploration. Aim: This study aimed to examine the frequency of alcohol dependence in suicidal survivors and assess the association of sociodemographic and clinical variables with the severity of dependence in suicide attempters. Materials and Methods: It is a hospital-based, cross-sectional, observational study set in a tertiary care institute where a total of 175 admitted cases of suicidal attempt were included. Patients referred to the department of psychiatry of a teaching hospital in Andhra Pradesh within the study period were enrolled after informed consent. With usual detailed workup, alcohol dependence was ascertained. Relevant information was recorded in a pro forma. Alcohol use/dependence was grouped into various categories in relation to suicidal attempt. Results: Alcohol was consumed by 43.43% of suicide attempters. Alcohol dependence constituted of 30.29%. Severe dependence was present in 9.14% of participants. There was a positive correlation between suicidal intent, lethality of attempt, history of smoking, and psychiatric comorbidity with the groups segregated based on the severity of dependence. Conclusion: High suicidal intent and lethality of attempt are risk factors of attempt in moderate-to-severe dependence. Effective treatment of alcohol dependence can mitigate suicidal attempts.
Keywords: Alcohol dependence, alcohol use, cross-sectional, suicidal attempt, suicidal risk
|How to cite this article:|
Sreelatha P, Haritha G, R. Ryali V S, Janakiraman RP. Alcohol dependence syndrome in suicide attempters: A cross-sectional study in a rural tertiary hospital. Arch Med Health Sci 2019;7:195-200
|How to cite this URL:|
Sreelatha P, Haritha G, R. Ryali V S, Janakiraman RP. Alcohol dependence syndrome in suicide attempters: A cross-sectional study in a rural tertiary hospital. Arch Med Health Sci [serial online] 2019 [cited 2020 Jan 25];7:195-200. Available from: http://www.amhsjournal.org/text.asp?2019/7/2/195/273070
| Introduction|| |
Suicide is a fatal problem with global dissemination. According to the WHO, crude suicidal rates in countries of South East Asian region accounted for 13.2/100,000 population. Suicidal attempts tend to be twenty times more frequent than completed suicide. Several causes are implicated in suicide attempters and completers. Alcohol use has emerged as a major risk factor for suicide. Alcohol abuse/dependence has a strong link to suicidal ideation, attempt, and completed suicide. Earlier studies have addressed the relationship of alcohol and suicide in the context of acute alcohol use/intoxication, and heavy drinking.
Suicide in alcohol-dependent individuals was estimated at 7%–18%.,,, Inskip et al. observed that the lifetime risk of suicide was higher for alcohol dependence than those with affective disorders and schizophrenia. Alcohol-dependent individuals have a 60–120 times greater risk of suicide than the population without psychiatric diagnosis. Murphy and Wetzel in a review found that the lifetime risk of suicide among individuals with alcohol dependence treated in outpatient and inpatient settings was 2.2% and 3.4%, respectively. A psychological autopsy study found that acute use of alcohol and dependence was present in 21%–46% of all suicide completers. The severity of alcohol dependence is presumed to increase the risk of suicide. Alcohol-dependent individuals are at a 4.6 times greater risk for suicidal ideation and a 6.5 times greater risk for attempted suicide than their nonalcoholic counterparts. In the Indian context as well, alcohol dependence and abuse were found in 35% of suicides, emphasizing the impact of alcohol dependence in mortality due to suicide.
The association between alcohol use and suicidal behaviors is complex and cannot be fully comprehended, particularly in adult populations with different degrees of alcohol consumption. Two dimensions of alcohol use including (1) acute use of alcohol/intoxication just prior to attempt and (2) alcohol abuse/dependence are associated with completed suicide and suicidal attempt. Although interrelated, these two dimensions are distinct. In alcohol-dependent individuals, suicide can occur even when the individual is not intoxicated. More than 40% of all patients seeking treatment for alcohol dependence report a suicidal attempt at some point in their lifetime.
Although there is a strong body of evidence which has shown that suicidal attempts are consistently interlinked with alcohol dependence syndrome, much research is needed in the Indian context as well. It is, therefore, essential for researchers to examine alcohol dependence and its association in suicide attempters. The present study was undertaken to examine the frequency of alcohol dependence in suicidal survivors and assess the association of sociodemographic and clinical variables with the severity of dependence in suicide attempters.
| Materials and Methods|| |
It was a cross-sectional observational study conducted in a tertiary care medical hospital with admissions of cases of suicidal attempts from the surrounding rural strata. Cases consist of suicidal survivors referred to the psychiatric department for assessment and for further interventions. The study was done after taking informed consent from the patients and obtaining the ethical approval from the institutional ethical board.
A total of 175 patients, of both sexes, fulfilling the following inclusion criteria, were enrolled during the study period from December 2016 to February 2018 at P.E.S Institute of Medical Sciences and Research, Kuppam, Andhra Pradesh:
- Age ≥18 years
- Giving informed consent to participate in the study.
The exclusion criteria were:
- Mental retardation
- Neurological or medical conditions affecting the cognitive status of patients
- Any other psychoactive substance use except nicotine (other than alcohol and nicotine have been excluded)
- Medically unstable cases of suicide attempters who were not in a condition to participate in the study.
Relevant information collected from the patients and their reliable attendants was recorded in a semi-structured pro forma. Details regarding the sociodemographic profile; suicide-related details such as lethality, intent, suicidal ideation, and previous attempts, and alcohol-related details such as frequency, quantity, and age at the onset of alcohol consumption were recorded. The pro forma also included details regarding the presence of stressors, smoking history, and a history of psychiatric diagnosis. Psychiatric diagnosis was made as per the International Classification of Diseases-10 criteria by a qualified psychiatrist.
Rating scales used in the study are (1) Severity of Alcohol Dependence Questionnaire (SADQ) and (2) Beck Suicide Intent Scale.
The study population was segregated into two major groups, namely no alcohol-use group (absent) and alcohol use in suicide attempters' group (present). The alcohol-use group was further divided into subgroups based on the severity of alcohol use into occasional use, harmful use, mild degree of alcohol dependence, moderate degree of alcohol dependence, and severe degree of alcohol dependence. Statistical analyses were drawn comparing these groups, and the results were analyzed.
The data were entered into MS Excel version 2007 and further analyzed using STATA 14 (StataCorp., College Station, Texas, USA). The descriptive data were analyzed as follows: categorical data were analyzed using percentages, and the continuous data were analyzed using mean and standard deviation.
For inferential statistics, categorical variables were analyzed using the Chi-square test of significance. Logistic regression was used to study the association between several risk factors and the outcome. P < 0.05 was considered statistically significant.
| Results|| |
Out of the 175 individuals, 76 (43.43%) consumed alcohol. Occasional alcohol use was found in 9 (5.14%) individuals and harmful use in 14 (8%) individuals. Alcohol-dependent individuals made up 30.29% (n = 53) of the study population. The 53 dependent individuals were categorized further based on the SADQ as follows: mild dependence was observed in 9 (5.14%) individuals, moderate dependence in 28 (16%), and severe dependence in 16 cases (9.14%).
The sociodemographic and clinical variables in these major groups and subgroups were found to be statistically significant (P< 0.05) for, occupational status, education, family type, income, suicidal intent, lethality of attempt, history of smoking, and psychiatric diagnosis.
Majority of the severe alcohol-dependent population were older, were unskilled workers, were married, were primary level educated, were from rural background, and were with low income [Table 1].
In the study population, 38.28% (n = 67) had a psychiatric diagnosis; the most common psychiatric diagnosis was depression (n = 36, 20.57%), with 15.15% of depressive cases in the severe alcohol-dependent group. Consumption of poison was the most common mode (n = 70, 40%) of suicidal attempt. Drug overdose was the common mode in the severe alcohol-dependent group.
High suicidal intent in the severe alcohol-dependent group comprised of 28% (n = 3) of individuals. The severe alcohol-dependent group had 14.67% (n = 11) of lethal attempt. A total of 101 individuals (57.7%) had perceived stressors prior to suicidal attempt. Previous suicidal attempts were present in 26 (14.86%) individuals and 53 (30.29%) individuals had suicidal ideation. History of smoking was positive in 41 (23.43%) suicide attempters.
Majority (n = 34, 19.43%) had age at the onset of alcohol consumption at 21–30 years. In the study population, 2–4 drinks/day of consumption (n = 52, 29.71%) with a frequency of >4 times/week (n = 30, 17.14%) occurred frequently.
Suicidal ideation, previous suicidal attempt, and perceived stressors in the categorized groups were not found to be statistically significant [Table 2]. Among those with suicidal attempt, those with high intent were 6.23 times more likely to be of moderate-to-severe dependence compared to those with low intent. High intent continued to be associated with moderate-to-severe dependence of suicide attempters after adjusting for other variables; odds ratio (OR) = 5.65, 95% confidence interval (CI) (1.43–22.23), P = 0.013. Lethal attempts were associated with moderate-to-severe dependence of suicide attempters; OR = 5.07, 95% CI (2.03–12.63), P ≤ 0.001. History of smoking was 9.82 times more likely to occur in suicide attempters with moderate-to-severe alcohol dependence; 95% CI (4.02), P ≤ 0.001 [Table 3].
|Table 3: Risk factors of suicidal attempt in moderate-to-severe alcohol-dependent suicide attempters|
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| Discussion|| |
This study documented the relationship between alcohol dependence and suicide attempters and explored the association of various psychosocial variables with the severity of alcohol dependence. Results showed that moderate-to-severe alcohol dependence was frequent (25.14%) in suicide attempters, which is comparatively higher to a study done in Nepal where alcohol dependence was present in 13.3% of suicide attempters. In our study, suicidal ideation was present in 24.44% of alcohol-dependent individuals.
Our study showed that certain sociodemographic and clinical variables of alcohol-dependent individuals increase the likelihood of suicidal attempts. Of particular interest was that those with severe alcohol dependence were older, were unskilled workers, were married, were primary level educated, and were with low income. These findings provide the ground for monitoring individuals with these characteristics.
In the current study, majority of the severe alcohol-dependent individuals belonged to the age group of 51–60 years; this finding concurs with a previous study which found that middle-aged and older patients with alcohol dependence are at a greater risk for suicide than younger patients. Most of the suicide attempters with moderate-to–severe alcohol dependence were males, which is contrary to a finding that females attempt suicide three times more likely than males. The lower suicidal rates among women suggest that women have more healthier coping skills than men. It was also suggested that higher suicidal rate in men may be related to higher consumption of alcohol, which reflects on the severity of dependence. However, as the number of females in the study group was minimal (n = 5), further research needs to focus on female alcoholics to substantiate or negate the findings in the current study.
As observed in this study, suicide attempters in the severe alcohol-dependent group were with low income and low educational status, which is similar to a research stating that socially disadvantaged backgrounds characterized by low socioeconomic status, limited educational achievement, low income, and poverty increase the chances of suicidal attempt.,
Nearly 74.86% of the individuals were from rural population. Chemicals such as organophosphorous compounds are easily available, which makes suicide a convenient method and thus influence suicide in rural areas, a finding which is in agreement with our study where majority had used organophosphorous compounds.
It was observed in our study that moderate-to-severe alcohol-dependent group had higher proportion of lethal attempts, high intent, previous suicidal attempts with the presence of significant stressors, history of smoking, and psychiatric comorbidity particularly depression, when compared with suicide attempters with lesser degree of alcohol consumption. Among the several factors associated with a risk of suicide in patients with alcohol dependence, depression is of prime importance. Several researchers have pointed out that among alcohol-dependent individuals who committed suicide, 45%–70% meet the criteria of major depressive episode before a suicide., One possible explanation could be that alcohol can have negative effects on the mental well-being of an individual, causing depression and increasing the risk of suicide. In a study done in Korea, it was observed that depression and suicidal ideation were significant correlates of suicidal attempt in alcohol-dependent patients.
In an article by Sher, it was concluded that the risk factors for suicide include being male, older than 50 years of age, living alone, being unemployed, poor social support, interpersonal losses, continued drinking, consumption of a greater amount of alcohol, a major depressive episode, serious medical illness, suicidal communication, and prior suicidal behavior. Many of these findings synchronize with the observations made in the current study. Another study also resonates that, the higher the degree of alcohol severity, the higher the chances of a suicidal attempt. Alcohol-dependent individuals are at risk for subsequent suicidal attempts. Alcohol may play a role through various factors that influence negative life events, negative mood states, and behaviors such as disinihibition and aggression and thus, trigger suicide.
In a cohort study from Korea, it was found that increased frequency of drinking, larger quantity of alcohol consumption per drinking day, and a large amount of average alcohol consumption were associated with a higher risk of suicide, which is similar to the findings in the current study. Because the frequency and quantity of alcohol consumption gives an estimate of the severity of alcohol dependence, it can be indirectly concluded that, the greater the severity, the higher are the chances of suicide.
High suicidal intent (OR = 6.23, 95% CI [2.06–18.85], P = 0.001) and lethal attempt (OR = 5.07, 95% CI [2.03, 12.63]), P = 0.001) emerged as risk factors of suicidal attempt in moderate-to-severe alcohol dependence.
Limitations in this study include the lack of a validated psychometric assessment for suicidal ideation/lethality of attempt, assessment of stressors, and psychiatric diagnosis. Due to the cross-sectional nature of this study, we weres unable to assess the implications of alcohol dependence, its treatment, and its effects on subsequent suicidal attempts, and the causality of alcohol dependence and suicidal behavior could not be addressed. Future research with prospective study design is suggested to address this issue. Our study did not explore the role of impulsive and aggressive personality traits which are known predictors of suicide.
| Conclusion|| |
Within the scope of these limitations, our data conclude that alcohol dependence occurs frequently in suicide attempters. There is a positive correlation between occupation, education, family type, and income in the categorized groups. Suicidal intent, lethality of attempt, history of smoking, and psychiatric comorbidity were statistically significant in the individual groups. There is evidence to prove that suicidal attempts are less likely to occur in the year subsequent to the treatment of alcohol dependence. Hence, an intensive focus on the prevention and management of alcohol-use disorders is warranted. Development of integrated treatment interventions is thoroughly recommended. Several areas such as developing problem-solving skills, emotion regulation, distress tolerance, emphasizing on intrapersonal and interpersonal conflicts that provoke a suicidal attempt, motivational enhancement, and relapse prevention can be addressed. Strategies and policies on the awareness, regulation, and restriction of alcohol consumption can have a positive impact on reducing and preventing suicides.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Centers for Disease Control and Prevention. Understanding Suicide: Fact Sheet. Atlanta: Centers for Disease Control and Prevention; 2015.
Darvishi N, Farhadi M, Haghtalab T, Poorolajal J. Alcohol-related risk of suicidal ideation, suicide attempt, and completed suicide: A meta-analysis. PLoS One 2015;10:e0126870.
Cherpitel CJ, Borges GL, Wilcox HC. Acute alcohol use and suicidal behavior: A review of the literature. Alcohol Clin Exp Res 2004;28:18S-28S.
Bagge CL, Conner KR, Reed L, Dawkins M, Murray K. Alcohol use to facilitate a suicide attempt: An event-based examination. J Stud Alcohol Drugs 2015;76:474-81.
Wilcox HC, Conner KR, Caine ED. Association of alcohol and drug use disorders and completed suicide: An empirical review of cohort studies. Drug Alcohol Depend 2004;76 Suppl: S11-9.
Roy A, Linnoila M. Alcoholism and suicide. Suicide Life Threat Behav 1986;16:244-73.
Rathi P, Quadri M, Mishra A. To study prevalence of attempted suicide in patients with the diagnosis of alcohol dependence/abuse. MedPulse Int Med J 2016;3:10-3.
Murphy GE, Wetzel RD, Robins E, McEvoy L. Multiple risk factors predict suicide in alcoholism. Arch Gen Psychiatry 1992;49:459-63.
Murphy GE. Suicide in Alcoholism. New York: Oxford University Press; 1992.
Inskip HM, Harris EC, Barraclough B. Lifetime risk of suicide for affective disorder, alcoholism and schizophrenia. Br J Psychiatry 1998;172:35-7.
Murphy GE, Wetzel RD. The lifetime risk of suicide in alcoholism. Arch Gen Psychiatry 1990;47:383-92.
Giner L, Carballo JJ, Guija JA, Sperling D, Oquendo MA, Garcia-Parajua P, et al.
Psychological autopsy studies: The role of alcohol use in adolescent and young adult suicides. Int J Adolesc Med Health 2007;19:99-113.
Sher L. Alcohol consumption and suicide. Q J Med 2006;99:57-61.
Kessler RC, Borges G, Walters EE. Prevalence of and risk factors for lifetime suicide attempts in the national comorbidity survey. Arch Gen Psychiatry 1999;56:617-26.
Vijaykumar L. Suicide and its prevention: The urgent need in India. Indian J Psychiatry 2007;49:81-4.
] [Full text]
Lamis DA, Malone PS. Alcohol use and suicidal behaviors among adults: A synthesis and theoretical model. Suicidol Online 2012;3:4-23.
Norström T, Rossow I. Alcohol consumption as a risk factor for suicidal behavior: A systematic review of associations at the individual and at the population level. Arch Suicide Res 2016;20:489-506.
Conner KR, Bagge CL, Goldston DB, Ilgen MA. Alcohol and suicidal behavior: What is known and what can be done. Am J Prev Med 2014;47:S204-8.
Wojnar M, Ilgen MA, Jakubczyk A, Wnorowska A, Klimkiewicz A, Brower KJ. Impulsive suicide attempts predict post-treatment relapse in alcohol-dependent patients. Drug Alcohol Depend 2008;97:268-75.
Roy A. Distal risk factors for suicidal behavior in alcoholics: Replications and new findings. J Affect Disord 2003;77:267-71.
Shakya DR. Alcohol use/abuse in suicide attempters: A study in psychiatric out-patient clinic of a teaching hospital of Eastern Nepal. MOJ Addict Med Ther 2018;5:27-31.
Conner KR, Beautrais AL, Conwell Y. Moderators of the relationship between alcohol dependence and suicide and medically serious suicide attempts: Analyses of Canterbury suicide project data. Alcohol Clin Exp Res 2003;27:1156-61.
Sher L, Oquendo MA, Mann JJ. Risk of suicide in mood disorders. Clin Neurosci Res 2001;1:337-44.
Sher L. Risk and protective factors for suicide in patients with alcoholism. ScientificWorldJournal 2006;6:1405-11.
Gould MS, Fisher P, Parides M, Flory M, Shaffer D. Psychosocial risk factors of child and adolescent completed suicide. Arch Gen Psychiatry 1996;53:1155-62.
Beautrais AL. Risk factors for suicide and attempted suicide among young people. Aust N
Z J Psychiatry 2000;34:420-36.
Henriksson MM, Aro HM, Marttunen MJ, Heikkinen ME, Isometsä ET, Kuoppasalmi KI, et al.
Mental disorders and comorbidity in suicide. Am J Psychiatry 1993;150:935-40.
Conner KR, Duberstein PR, Conwell Y. Age-related patterns of factors associated with completed suicide in men with alcohol dependence. Am J Addict 1999;8:312-8.
Choi JY, Ko HJ, Kim CO, Kim BR. Risk factors of suicide attempt in male patients with alcohol dependence. J Korean Neuropsychiatr Assoc 2013;52:205-14.
Wojnar M, Ilgen MA, Czyz E, Strobbe S, Klimkiewicz A, Jakubczyk A, et al.
Impulsive and non-impulsive suicide attempts in patients treated for alcohol dependence. J Affect Disord 2009;115:131-9.
Zhang Y, Conner KR, Phillips MR. Alcohol use disorders and acute alcohol use preceding suicide in China. Addict Behav 2010;35:152-6.
Conner KR, Duberstein PR, McCloskey MS. Psychiatric risk factors for suicide in the alcohol-dependent patient. Psychiatr Ann 2008;38:742-8.
Yi SW, Jung M, Kimm H. Usual alcohol consumption and suicide mortality among the Korean elderly in rural communities: Kangwha cohort study. J Epidemiol Community Health 2016;70:778-83.
Ilgen MA, Harris AH, Moos RH, Tiet QQ. Predictors of a suicide attempt one year after entry into substance use disorder treatment. Alcohol Clin Exp Res 2007;31:635-42.
[Table 1], [Table 2], [Table 3]