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The aim of this paper was to review the literature concerning the relationship between suicide and substance abuse behaviours among adolescents, focusing on epidemiology, comorbidity and preventive programmes. We performed a Pubmed/Medline, Scopus, PsycLit and PsycInfo search to identify all papers and book chapters during the period between 1980 and 2011. Adolescents with substance abuse disorder who attempt or complete suicide can be characterized as having mood disorders, stressful life events, interpersonal problems, poor social support, lonely lives and feelings of hopelessness. The research supports the existence of a strong relationship between suicide and substance abuse. Preventive programmes should be based on the detection of risk factors associated with both suicide and substance abuse disorder. Management programmes should combine different therapeutic strategies such as peer-to-peer education, school-based programmes, psychotherapy and pharmacological treatment. Evidence suggests that targeted suicide prevention programmes can be delivered which reduce the burden associated with substance abuse and suicide in youths.
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ORIGINAL PAPER
Substance abuse and suicide risk among adolescents
Maurizio Pompili Gianluca Serafini Marco Innamorati Massimo Biondi
Alberto Siracusano Massimo Di Giannantonio Giancarlo Giupponi
Mario Amore David Lester Paolo Girardi Anne Maria Mo
¨ller-Leimku
¨hler
Received: 9 August 2011 / Accepted: 10 January 2012 / Published online: 31 January 2012
ÓSpringer-Verlag 2012
Abstract The aim of this paper was to review the liter-
ature concerning the relationship between suicide and
substance abuse behaviours among adolescents, focusing
on epidemiology, comorbidity and preventive programmes.
We performed a Pubmed/Medline, Scopus, PsycLit and
PsycInfo search to identify all papers and book chapters
during the period between 1980 and 2011. Adolescents
with substance abuse disorder who attempt or complete
suicide can be characterized as having mood disorders,
stressful life events, interpersonal problems, poor social
support, lonely lives and feelings of hopelessness. The
research supports the existence of a strong relationship
between suicide and substance abuse. Preventive pro-
grammes should be based on the detection of risk factors
associated with both suicide and substance abuse disorder.
Management programmes should combine different
therapeutic strategies such as peer-to-peer education,
school-based programmes, psychotherapy and pharmaco-
logical treatment. Evidence suggests that targeted suicide
prevention programmes can be delivered which reduce the
burden associated with substance abuse and suicide in
youths.
Keywords Drug abuse Alcohol abuse Suicide
Youths Prevention
Introduction
Adolescence is a challenging period of cognitive, biologi-
cal, physiological and psychological transition, occurring
between 10 and 19 years of age [22]. The transition to
M. Pompili G. Serafini M. Innamorati P. Girardi
Department of Neurosciences, Mental Health and Sensory
Functions, Suicide Prevention Center, Sant’Andrea Hospital,
Sapienza University of Rome, Rome, Italy
M. Pompili
McLean Hospital, Harvard Medical School, Belmont, MA, USA
M. Pompili (&)
Department of Neuroscience, Mental Health and Sensory
Organs—Sant’Andrea Hospital, Sapienza University of Rome,
1035-1039 Via di Grottarossa, 00189 Rome, Italy
e-mail: maurizio.pompili@uniroma1.it
M. Biondi
Department of Psychiatry and Psychological Medicine,
Sapienza Universita
`di Roma, Rome, Italy
A. Siracusano
Department of Neuroscience, Division of Psychiatry,
University of Rome ‘‘Tor Vergata’’, Rome, Italy
M. Di Giannantonio
Neuroscience and Imaging Department, University of Chieti,
Chieti, Italy
G. Giupponi
Department of Psychiatry, Bolzano, Italy
M. Amore
Department of Neurosciences, Division of Psychiatry, University
of Parma, Parma, Italy
D. Lester
The Richard Stockton College of New Jersey, Pomona, NJ, USA
A. M. Mo
¨ller-Leimku
¨hler
Department of Psychiatry, Ludwig-Maximilians-University
of Munich, Munich, Germany
123
Eur Arch Psychiatry Clin Neurosci (2012) 262:469–485
DOI 10.1007/s00406-012-0292-0
adolescence leads to needs for independence, identity for-
mation and acceptance by peers. All of these contribute to
risk-taking behaviours, suicidal ideation and suicidal
behaviour.
According to the World Health Organization [115],
suicide is the third leading cause of death among those
aged 15–24, after car accidents and cancer. Additionally,
suicide attempts represent the main reason for referral to
child and adolescent psychiatric emergency services [77].
Despite the fact that suicide mortality in middle-aged
and older persons has recently decreased in several Euro-
pean and North American countries, suicides among youths
have risen dramatically in recent decades [76], and
researchers have associated this increase in youth suicide
with the widespread use of alcohol and other drugs among
adolescents [7,47,112].
Both cross-sectional and retrospective evidence in ado-
lescent and adult populations have reported an association
between suicidal behaviours and substance use. Goldsmith
et al. [35] reported a rapid increase in drug abuse in the
USA in the years after 1960 especially in adolescents.
Adolescent suicidal behaviour also increased by about
300%. Substance using in adolescence has been proposed
as a relevant risk factor for suicidal behaviours [97]. Wines
et al. [114] found that 28% of inpatients in drug abuse
treatment centres had histories of suicidal ideation and 21%
had attempted suicide. Additionally, after 2 years of sub-
stance abuse treatment, 19% continued to have suicidal
ideation and 7% had made suicide attempts. It was also
suggested that the estimated risk for suicide in the presence
of alcohol-related disorders was about four times greater in
men and five times greater in women than in its absence
[100]. Shneider et al. [101] reported that alcohol-related
disorders (DSM-IV alcohol dependence) were more often
diagnosed in suicide victims than in controls (OR =8.8,
95% CI 4.4–17.7).
Based on the existing literature, this systematic review
first aimed to investigate whether there is an association
between the substance use/abuse/dependence and suicidal
behaviour in clinical and non-clinical samples. Our second
aim was to ascertain whether substance use/abuse/depen-
dence may be considered as a specific risk factor for sui-
cide after controlling for a number of potentially
confounding factors.
Materials and methods
To achieve a high standard of reporting, we have adopted
‘Preferred Reporting Items for Systematic Reviews and
Meta-Analyses’ (PRISMA) guidelines [69]. In order to
provide a new and timely systematic review of substance
abuse and suicidal behaviour, we performed a Pubmed/
Medline, Scopus, PsycLit and PsycInfo search to identify
all papers and book chapters during the period between
1980 and 2010. The search used the following terms:
(suicide OR suicide attempt OR ideation OR suicidal
behaviour) AND (epidemiology OR rates OR trends OR
incidence) AND (drug OR substance abuse OR drug abuse
OR substance disease OR comorbidity) AND (‘prevention’
OR ‘intervention’ OR ‘future implications’). Specifically,
in order to adequately focus on the specific field of interest,
the following search query was used in Pubmed: (suicid*
[TI] AND substanc* [TI]). This search in Medline gener-
ated 182 articles. The same search strategy was used in
Scopus rendering 4 additional articles and in PsycLit/Psy-
cInfo (specifying ‘suicide AND substance abuse’ and
deleting ‘[TI]’) providing 43 further articles. The reference
lists of the articles included in the review were manually
checked yielding 27 additional articles that might be
potentially considered for screening. The Pubmed, Scopus
and PsycLit/PsycInfo databases revealed a total of 151
potentially relevant articles after the removal of duplicates.
Figure 1summarizes the search strategy used for selecting
studies (identification, screening, eligibility, inclusion
process).
Data collection
Only those articles published in peer-reviewed journals
were included. Where a title or abstract seemed to
describe a study eligible for inclusion, the full article was
obtained and examined to assess its relevance based on
the inclusion criteria. Two independent researchers con-
ducted a two-step literature search. Any discrepancies
between the two reviewers who, blind to each other,
examined the studies for the possible inclusion were
resolved by consultations with a senior author. Included
were all contributions that explicitly mention the associ-
ation between substance use and suicidal behaviour in
clinical and non-clinical (healthy) samples. Exclusion
criteria are the following: (1) studies including samples
with mean age [18 were excluded years; (2) studies
published before 1980; (3) articles without abstracts or
abstracts that did not explicitly mention suicidal behav-
iour, substance use, abuse and dependence; (4) articles not
published in English language; and (5) articles having low
relevance to the main theme. Included papers were
restricted to those in English with the exception of one
Norwegian study [75] included in Table 1because it was
considered to be of particular interest. All 151 articles
were critically evaluated: 24 of these were excluded
because they were not published in peer-reviewed jour-
nals, were without abstracts, had abstracts that did not
explicitly mention suicidal behaviour (suicidal attempts
and ideation) and substance abuse, and are articles with a
470 Eur Arch Psychiatry Clin Neurosci (2012) 262:469–485
123
publication date before 1980. This left 127 full-text arti-
cles of which 110 articles were excluded because they
were not published in English language, had low rele-
vance to the main theme, included unclear data regarding
materials and method and number of patients analyzed.
Thus, 17 articles meeting our inclusion criteria were
included in the present review.
Data extraction
Data were independently collected by the two reviewers.
The following characteristics were extracted from the 17
included articles in Table 1: author/s and publication year,
study design, sample size, eventual follow-up, conclusions
and main risk factors.
The principal reviewer (MP) inspected all reports. Then,
three reviewers (MP, PG and GS) independently inspected
all citations of studies identified by the search and grouped
them according to the topic of the papers. Reviewers
acquired the full article for all papers located. Where dis-
agreement occurred, this was resolved by discussion with
MA who also with double-blind features inspected all
articles located and grouped them following the major
areas of interest identified by all authors. If doubt
remained, the study was put on the list of those awaiting
assessment, pending acquisition of more information. We
excluded from our analysis any studies vaguely reporting
on substance abuse in adolescence or using inadequate or
unclear diagnostic criteria for such disorders or those
inappropriately assessing the impact of substance abuse on
suicide risk. Results of this search are presented in the
paragraphs regarding the role of substance abuse in the
precipitation of suicide risk.
Summary measures
Studies were rated for quality using the following eligi-
bility criteria: (i) the representativeness of the sample
from the general population (0–2 points), (ii) the presence
of a control group (1 or 2 points), (iii) presence of follow-
up [1 year (1 or 2 points), (iv) evidence-based measures
of assessment (e.g. the use of the SCID-I for the diagnosis
of the substance abuse/dependence or other psychometric
evaluation) (1 or 2 points), (v) the presence of two
independent raters who blindly diagnosed the substance
abuse/dependence (1 or 2 points), (vi) a statistical eval-
uation of the interrater reliability (1 or 2 points) and (vii)
evidence-based measures for assessing suicide or suicide
attempts (1 or 2 points). Quality ratings had 14 as the
maximum score.
Studies were differentiated in the following way: good
quality ([11 points)—most or all criteria being fulfilled,
and where they were not met, the study conclusions were
thought very unlikely to alter; moderate quality (6–11
Fig. 1 Search strategy used for
selecting studies (identification,
screening, eligibility, inclusion
in the systematic review)
Eur Arch Psychiatry Clin Neurosci (2012) 262:469–485 471
123
Table 1 Relevant studies about substance abuse and suicide risk in adolescents and young adults
Study Design Sample size Eventual
follow-up
Conclusions Main risk factors Quality
score
Quality
differentiation
Darke and
Ross [24]
Review article on suicide rates,
suicide risk factors and methods
employed for suicide among
heroin users
Not reported No Heroin users are 14 times more likely
than peers to die from suicide. They
also attempted suicide more frequently
than that of community samples. Risk
factors for suicide were
psychopathology, family dysfunction
and social isolation as well as poly-
drug use. Drugs but not heroin as a
method of suicide appear to play a
relevant role in suicide among this
group
1. Psychopathology
2. Family dysfunction
3. Social isolation
4. Poly-drug use
I=2
II =2
III =0
IV =1
V=2
VI =2
VII =2
Total
score =11
Moderate
quality
Roy [94] Case–control study comparing
opiate-dependent patients who had
and had not attempted suicide
246 opiate-
dependent
patients
No One hundred of the 246 opiate-dependent
patients had attempted suicide, and
significantly more of the opiate-
dependent patients who had attempted
suicide had a family history of both
completed and attempted suicide.
Opiate-dependent patients who had
attempted suicide reported significantly
more childhood emotional abuse,
physical abuse, sexual abuse and
emotional and physical neglect.
Moreover, opiate-dependent patients
who had attempted suicide were found
to be significantly more introverted,
hostile and neurotic. Finally,
significantly more of the patients who
had attempted suicide were female and
unemployed
1. Family history of
both completed and
attempted suicide
2. Childhood emotional
abuse
3. Childhood physical
abuse
4. Childhood sexual
abuse
5. Emotional and
physical neglect
6. Introversion, hostility
and neuroticism.
7. Being female and
unemployed
I=2
II =2
III =0
IV =1
V=2
VI =2
VII =2
Total
score =11
Good quality
Havens
et al. [42]
Cross-sectional study investigating
the relationship between suicidal
ideation with injection drug users
(IDUs) and non-injection drug
users (NIDUs)
244 injection
drug users
and 73 non-
injection
drug users
No Suicidal ideation was present in 27% of
the IDU patients vs. 14% among the
NIDU patients, p =0.003. After
controlling for confounding lifestyle
factors, including homelessness,
depressive symptoms and gay/lesbian/
bisexual identity, the association was
no longer significant. The poor
sociopsychological background
(psychiatric disorders, sexual
orientation, isolation), which is
frequent among injection drug users
may be responsible for the increased
suicidal ideation found in IDUs
1. Psychiatric disorders
2. Sexual orientation
3. Isolation
I=2
II =2
III =0
IV =1
V=0
VI =1
VII =0
Total
score =6
Moderate
quality
472 Eur Arch Psychiatry Clin Neurosci (2012) 262:469–485
123
Table 1 continued
Study Design Sample size Eventual
follow-up
Conclusions Main risk factors Quality
score
Quality
differentiation
Kalyoncu
et al. [50]
Cross-sectional examination of the
socio-demographic and clinical
characteristics
108 young
adult
heroin-
dependent
inpatients
No Both the female and male suicide
attempters were significantly younger
at the onset of heroin use than those
who had not attempted suicide. The
starting age of heroin use may be a risk
factor for suicide attempts. The suicide
attempters had experienced greater
family psychopathology and
dysfunction than the non-attempters
and had significantly higher scores on
the Childhood Trauma Questionnaire.
Previous traumatic experiences are
strongly associated with suicide
attempts in young adult heroin-
dependent patients. In particular, the
male suicide attempters more often met
the criteria for depressive, anxiety and
antisocial personality disorders
1. Younger age
2. The starting age of
heroin use
3. Family
psychopathology and
dysfunction
4. Childhood traumatic
experiences
5. Depressive disorder
6. Anxiety disorder
7. Antisocial
personality disorder
I=2
II =0
III =0
IV =2
V=1
VI =2
VII =0
Total
score =7
Moderate
quality
Marzuk
et al. [63]
Individual review of autopsy and
toxicological records
Not reported No The prevalence of cocaine use among
young Hispanic males who committed
suicide was 45%. Persons who were
young, black or Hispanic and who had
used alcohol immediately before the
fatal injury were most likely to have
been recent cocaine users. After
controlling for demographic variables
and alcohol use, subjects who
committed suicide with firearms were
twice as likely to have used cocaine as
those who used other methods
1. Cocaine use
2. Younger age
3. Black or Hispanic
race
4. Alcohol consumption
immediately before
the fatal injury
I=2
II =0
III =0
IV =0
V=2
VI =2
VII =0
Total
score =6
Moderate
quality
Roy [93] Case–control study 214 cocaine-
dependent
patients
No 39% of the cocaine-dependent patients
had attempted suicide at some time in
their lives, more often had a family
history of suicidal behaviour and
reported significantly more childhood
trauma. They also had higher
personality scores for introversion,
neuroticism and hostility; they had
significantly more comorbidity with the
use of other substances, as well as
psychiatric and physical disorders
1. Family history of
suicidal behaviour
2. Childhood trauma
3. Introversion,
neuroticism and
hostility
4. Psychiatric disorders
5. Physical disorders
I=2
II =2
III =0
IV =2
V=0
VI =2
VII =0
Total
score =8
Moderate
quality
Eur Arch Psychiatry Clin Neurosci (2012) 262:469–485 473
123
Table 1 continued
Study Design Sample size Eventual
follow-up
Conclusions Main risk factors Quality
score
Quality
differentiation
Waldrop
et al.
[111]
National cross-sectional Survey of
Adolescents
2002
adolescents
(aged
12–17)
No Sample prevalences of suicidal ideation
and attempts were 24.3 and 3.3%,
respectively, yielding weighted
population prevalence estimates of 23.3
and 3.1%. Suicidal ideation was
positively associated with female
gender, age, family, alcohol and drug
problems, violence exposure, lifetime
depression and PTSD. Suicide attempts
were associated with female gender,
age, sexual and physical assault,
lifetime substance abuse or
dependence, PTSD and depression
1. Psychopathology
2. Female gender
3. Age
4. Sexual and physical
assaults
I=2
II =0
III =0
IV =0
V=1
VI =2
VII =1
Total
score =6
Moderate
quality
Garlow
[33];
Garlow
et al. [34]
Retrospective analysis of records of
the Office of the Medical
Examiner of all completed
suicides
416 cocaine
users
No Almost all (94.6%) of the suicides in
whom cocaine was detected were
male, 51.4% of the cocaine-positive
suicides were African American men
and 43.2% were white men. Most
(86.7%) of African American
teenagers did not use substances
before committing suicide, whereas
50.0% of the white teenage
victims had used one or both
substances, with 41.7% of the white
teenagers having used ethanol.
Ethanol use was much more
common among white victims
of all age groups
1. Being male
2. Younger age
3. Being white or
African American
4. Cocaine or ethanol
detected at autopsy
I=2
II =0
III =0
IV =0
V=2
VI =0
VII =0
Total
score =4
Low quality
Innamorati
et al. [48]
Cross-sectional study 340 young
adults
No 14.7% were drug users and 24.1%
drinkers. Alcohol and drug misuse was
significantly associated with reasons for
living, hopelessness, suicidal attitudes
and depression. After multiple
regression analysis, the Drug Abuse
Screening Test, the Zung Depression
Scale and Loss of Motivation were
positive predictors of suicide risk
with Survival and Coping Beliefs as
negative predictors. Cannabis
may be associated with risky
health behaviour
1. Alcohol and drug
misuse
2. Higher scores on the
Zung Depression
Scale
3. Loss of motivation
I=2
II =0
III =0
IV =2
V=2
VI =2
VII =2
Total
score =10
Moderate
quality
474 Eur Arch Psychiatry Clin Neurosci (2012) 262:469–485
123
Table 1 continued
Study Design Sample size Eventual
follow-up
Conclusions Main risk factors Quality
score
Quality
differentiation
Beautrais
et al. [2]
Case–control study 302 cases vs.
1,028
controls
No Subjects who had made serious suicide
attempts had significantly higher rates
of cannabis abuse/dependence than
comparison subjects presumably
related to the socio-demographic
disadvantages and disadvantaged
childhood family circumstances. After
controlling for confounding factors and
comorbid psychiatric disorder, the odds
ratio between cannabis abuse/
dependence and making a serious
suicide attempt was 2.0 and only
marginally statistically significant
1. Cannabis abuse/
dependence
2. Socio-demographic
disadvantaged
childhood family
circumstances
3. Comorbid mood
disorder, other
substance use disorder
and antisocial
personality disorder
I=2
II =2
III =0
IV =2
V=1
VI =2
VII =1
Total
score =10
Moderate
quality
Fergusson
et al. [32]
21-year longitudinal study 1,265
adolescence/
young adults
First
evaluation =at
birth
T
1
=4 months
T
2
=1 year
T
3
=annual
intervals up to
age 16 years
T
4
=at age
18 years
T
5
=at
21 years
Regular cannabis use was associated with
a dramatic increase in the risk of other
illicit drug use, even when confounding
variables were taken into account. In
addition, regular cannabis abuse was
associated with increases in
delinquency, depression and suicidal
behaviour. The adverse effects of
cannabis on adjustment seemed to be
most pronounced for younger users and
declined with increasing age
1. Cannabis use
2. Younger age
3. Delinquency in
cannabis users
4. Depression in
cannabis users
I=2
II =0
III =2
IV =2
V=2
VI =2
VII =2
Total
score =12
Good quality
Rey et al.
[89]
Cross-sectional study 1,261
adolescents
using
cannabis
No 1/4 of the sample reported having used
cannabis and males were twice as likely
as females to have used cannabis before
the age of 13. An association between
depression and cannabis use was found.
Cannabis use increased the incidence of
disruptive behaviours such as conduct
problems, tobacco smoking, excessive
drinking and the use of illicit drugs
1. Being male
2. Depression
3. Conduct problems,
tobacco smoking,
excessive drinking
and excessive use of
illicit drugs in
cannabis users
I=2
II =0
III =0
IV =2
V=2
VI =2
VII =0
Total
score =8
Moderate
quality
Eur Arch Psychiatry Clin Neurosci (2012) 262:469–485 475
123
Table 1 continued
Study Design Sample size Eventual
follow-up
Conclusions Main risk factors Quality
score
Quality
differentiation
Chabrol
et al. [18]
Cross-sectional study 248 high
school
students
No Those who had used cannabis at least
once in the last six months had
significantly higher rates of suicidal
behaviour, depression symptoms and
anxiety symptoms compared to non-
users. Cannabis use appeared to be an
independent predictor of suicidal
behaviour after controlling for
depression and anxiety symptoms
1. Cannabis use
2. Depression
symptoms and anxiety
symptoms in cannabis
users
I=2
II =0
III =0
IV =1
V=0
VI =0
VII =2
Total
score =5
Low quality
Epstein and
Spirito
[30]
Cross-sectional study 13,917 high
school
students
No Early alcohol onset, having had sex
before age 13, injection drug use and
being forced to have sex were
associated with suicidality across
gender. Smoking in girls was
associated with making a plan to
attempt suicide and actual suicide
attempts. Fighting was related to
suicidality for girls, while fighting in
school was related to suicidality for
boys
1. Early alcohol onset
2. Having had sex
before age 13
3. Injection drug use
4. Being forced to have
sex
5. Smoking in girls
6. Fighting for girls and
fighting in school for
boys
I=2
II =0
III =0
IV =1
V=0
VI =2
VII =0
Total
score =5
Low quality
Price et al.
[86]
Longitudinal study together with a
cross-sectional investigation using
the National Cause of Death
Register to correctly identify 600
suicides and undetermined deaths
50,087 male
military
conscripts
33-year follow-up 5,380 (10.7%) of subjects admitted to
having used cannabis while 41,394
(82.6%) had not. The association
between cannabis use and risk for
suicide was present using a crude
analysis (crude OR for ‘ever use’ 1.62,
95% CI 1.28–2.07), but after
adjustment for social and personal
factors, they failed to confirm the
increased risk for suicide in cannabis
users (adjusted OR =0.88, 95% CI
0.65–1.20). A significant association
was found between the use of other
drugs, instead of cannabis, with
undetermined deaths (adjusted
OR =2.06, 95% CI 1.11–3.80) but not
with definite suicides (adjusted
OR =1.13, 95% CI 0.73–1.75)
1. Use of other drugs
than cannabis
I=2
II =0
III =2
IV =2
V=2
VI =2
VII =1
Total
score =11
Good quality
476 Eur Arch Psychiatry Clin Neurosci (2012) 262:469–485
123
Table 1 continued
Study Design Sample size Eventual
follow-up
Conclusions Main risk factors Quality
score
Quality
differentiation
Pedersen
[75]
Longitudinal study 2033 young
adults
13-year follow-up No association between early
adolescence, suicidality and later
depression, while in the group in their
twenties, a highly significant
association was found between
cannabis use, suicide ideation and
suicide attempts even after controlling
for confounding factors. Subjects who
had used cannabis 11 ?times during
the past 12 months had an OR for later
suicide attempts of 2.9 (95% CI
1.3–6.1) and for suicidal ideation an
OR of 2.7 (95% CI 2.8–6.4)
1. Cannabis use
2. Younger age
I=2
II =0
III =2
IV =2
V=2
VI =2
VII =1
Total
score =11
Good quality
Studies were rated for quality using the following eligibility criteria: (i) the representativeness of the sample from the general population (0–1 points); (ii) the presence of a control group (1 or 2
points); (iii) presence of follow-up [1 year (0–2 points); (iv) evidence-based measures of assessment (e.g. the use of the SCID-I for the diagnosis of the substance abuse/dependence or other
psychometric evaluation) (0–2 points); (v) the presence of two independent raters who blindly diagnosed the substance abuse/dependence (0–2 points); (vi) a statistical evaluation of the
interrater reliability (0–2 points); (vii) evidence-based measures for assessing suicide or suicide attempts (0–2 points). Quality ratings had 14 as the maximum score
Studies were differentiated in the following way: (1) good quality (B11 points)—most or all criteria being fulfilled, and where they were not met, the study conclusions were thought very
unlikely to alter; (2) moderate quality (6–11 point)—some criteria being fulfilled, and where they were not met, the study conclusions were thought unlikely to alter; and (3) low quality (B5
points)—few criteria were fulfilled, and the conclusions of the study were thought very likely to alter. Caution was required in interpreting the results of these trials
Eur Arch Psychiatry Clin Neurosci (2012) 262:469–485 477
123
points)—some criteria being fulfilled, and where they were
not met, the study conclusions were thought unlikely to
alter; and low quality ([5 points)—few criteria were ful-
filled, and the conclusions of the study were thought very
likely to alter. Caution was required in interpreting the
results of these trials.
Results
According to our quality score system, the mean quality
score of the 17 studies that were included is of 7.7 points.
Based on quality differentiation, most of studies (ten)
resulted of moderate quality, four contributions were
judged of good quality and three of low quality,
respectively.
Suicide risk in alcohol users/abusers
Some of the studies included showed an association
between alcohol use disorders and suicidal risk (Table 1).
Rey et al. [89] in a cross-sectional study on 1,261 adoles-
cents with cannabis use found a close relationship between
cannabis use and excessive drinking plus cannabis use
increasing the incidence of disruptive behaviours.
Garlow [33] and Garlow et al. [34] in a retrospective
analysis found that ethanol use was much more common
among white completed suicides of all age groups. The
authors reported that 50.0% of the white teenage victims
had used ethanol or cocaine alone or both ethanol and
cocaine, with most of them (41.7%) having used predom-
inantly ethanol.
In 2008, Innamorati et al. [48] performed a cross-sec-
tional study of 340 young adults and reported that 24.1%
were drinkers. Alcohol misuse was significantly associated
with reasons for living, hopelessness, suicidal attitudes and
depression. After multiple regression analysis, the Drug
Abuse Screening Test was a positive predictor of suicide
risk.
Epstein and Spirito [30] in a cross-sectional study on
13,917 high school students later reported that early alco-
hol use onset was significantly associated with suicidality
across gender.
Suicide risk in other substance users/abusers
Several other studies showed an association between sub-
stance use disorders (SUD) and suicidal risk. Beautrais
et al. [2] in a case–control study on 302 cases versus 1,028
controls found that subjects who had made serious suicide
attempts had significantly higher rates of cannabis abuse/
dependence than comparison subjects presumably due to
the socio-demographic disadvantages and to childhood
adverse family circumstances. After controlling for con-
founding factors, the odds ratio between cannabis abuse/
dependence and making a serious suicide attempt was 2.0.
Fergusson et al. [32], in a 21-year longitudinal study con-
ducted on a sample of 1,265 adolescence/young adults,
reported that regular cannabis use was associated with a
increased risk of other illicit drug use, increases in delin-
quency, depression and suicidal behaviour.
Also, Rey et al. [89], in a cross-sectional study on 1,261
adolescents, have found that 25% reported having used
cannabis and males were twice as likely as females to
have used cannabis before the age of 13. Additionally, an
association between depression and cannabis use was
reported.
Pedersen [75], in a 13-year follow-up study conducted in
a sample of 2,033 young adults, found a highly significant
association between cannabis use, suicide ideation and
suicide attempts even after controlling for confounding
factors. Subjects who had used cannabis 11 times or more
during the past 12 months had an OR of 2.9 for later sui-
cide attempts and an OR of 2.7 for suicidal ideation.
However, not all studies included in the present review
reported a positive correlation between cannabis use and
suicidal risk. Price et al. [86], in a 33-year follow-up study
conducted together with a cross-sectional investigation
using the National Cause of Death Register on 50,087 male
military conscripts, reported that after adjustment for social
and personal confounding factors, the increased risk for
suicide was not confirmed in cannabis users (adjusted
OR =0.88). They instead suggested that a significant
association exists between the use of other additional
drugs, instead of cannabis, and undetermined deaths
(adjusted OR =2.06) but not definite suicides (adjusted
OR =1.13).
Some studies have reported an association between
heroin/opiate-dependent patients and suicidal risk. Darke
and Ross [24] wrote a review article on this topic finding
that heroin users are 14 times more likely than peers to die
from suicide. They also attempted suicide more frequently
than those in community samples.
Kalyoncu et al. [50], in a cross-sectional study of 108
young adult heroin-dependent inpatients, reported that both
the female and male suicide attempters were significantly
younger at the onset of heroin use compared to those who
had not attempted suicide. They concluded that the starting
age of heroin use may be a risk factor for suicide attempts.
Also, Roy [94], in a case–control study comparing 246
opiate-dependent patients who had and had not attempted
suicide, found that significantly more of the opiate-
dependent patients who had attempted suicide had a family
history of both completed and attempted suicide. Opiate-
dependent patients who had attempted suicide reported
significantly more childhood emotional, physical, sexual
478 Eur Arch Psychiatry Clin Neurosci (2012) 262:469–485
123
abuse and emotional and physical neglect, and they were
predominantly female, unemployed, significantly more
introverted, hostile and neurotic.
Havens et al. [42] conducted a cross-sectional study
investigating the suicidal ideation in injection drug users
(IDUs). They investigated a sample of 244 injection drug
users and 73 non-injection drug users (NIDUs) finding
that suicidal ideation was present in 27% of the IDUs
versus 14% of the NIDUs. However, after controlling for
confounding factors, the association was no longer sig-
nificant. The authors suggested that psychiatric disorders,
sexual orientation and isolation which are frequent
among IDUs may represent risk factors for increased
suicidal ideation.
Marzuk et al. [63], in an individual review of autopsy
and toxicological records, have reported that the preva-
lence of cocaine use among young Hispanic males who
committed suicide was 45%. Young, black or Hispanic
males who had used alcohol immediately before the fatal
injury were most likely to have been recent cocaine users.
After controlling for demographic variables and alcohol
use, subjects who committed suicide with firearms were
twice as likely to have used cocaine as those who used
other methods.
Roy [93], investigating 214 cocaine-dependent patients,
found that at least 39% of the cocaine-dependent patients
had attempted suicide, more often had a family history of
suicidal behaviour and reported significantly more child-
hood trauma. Cocaine-dependent patients also had higher
personality scores for introversion, neuroticism and hos-
tility and had significantly more comorbidity of substance
use and psychiatric and physical disorders.
Finally, the National Survey of Adolescents, conducted
to assess several suicidal risk factors, recruited 2002 ado-
lescents (aged 12–17) from the general population. Major
depressive episodes, post-traumatic stress disorder (PTSD)
and SUD were positively associated with an increased risk
for suicide attempts (as were female gender, age and
experience of sexual and physical assaults) [111].
Prevalence rates of substance use/abuse
among adolescent completed suicides
Back in the 1980s, Shafii and colleagues [103] reported a
dramatic increase in the referral of children and adolescents
with suicidal behaviour to their Child Psychiatric Service
in Louisville. They undertook psychological autopsies of
all children and adolescents who committed suicide as
determined by the Jefferson County coroner between 1980
and 1983. Twenty-four cases satisfied the criteria, but only
83% of the families agreed to participate in the study.
Compared to matched controls, suicides were more likely
to use non-prescribed drugs or alcohol (70 vs. 24%).
Marttunen et al. [62] investigated the prevalence of
mental disorders among 53 adolescent suicides in a
nationwide psychological autopsy study in Finland. The
authors reported that 26% of the suicides had alcohol abuse
or dependence. A more recent study of 106 adolescent
suicides aged 13–22 years old [78] indicated that 42% of
the victims had an alcohol use disorder or diagnostically
subthreshold alcohol misuse (16% alcohol abuse and 11%
alcohol dependence).
Brent et al. [11] investigated the psychiatric risk factors
for adolescent suicides in 67 suicides from 28 counties of
Western Pennsylvania. Suicides had an odds risk of 8.5 of
having substance abuse compared to matched controls. The
risk was even higher when substance abuse was comorbid
with affective disorders (OR =17.0 vs. 3.3). Brent et al.
[10] also investigated the characteristics of 27 adolescent
suicides from the Pittsburgh area. The authors found higher
incidences of alcohol and drug misuse in the suicides (40.7
vs. 17.9% as best estimate for overall substance abuse, and
37.0 vs. 16.1%, and 29.6 vs. 14.3%, respectively, for
alcohol abuse and other drug abuse).
More recently, Renaud et al. [88] compared fifty-five
adolescents who committed suicide with a control group of
living subjects using psychological autopsies. The preva-
lence rates for current substance and alcohol abuse were
13% (OR =5.365) for the suicides compared to 3% for the
control group. Furthermore, current mood disorders were
more common in suicides than in living subjects, 33 and
2%, respectively.
Prevalence rates of substance use/abuse
among adolescent suicide attempters
Several research studies have indicated that suicide
attempts are common in adolescents with SUD [5,17,
26], and that substance use is common in those seeking
treatment for suicidal behaviour [2931,106,112]. Vajda
and Steinbeck [107], in a retrospective record review of
112 adolescents (13–20 years old) who presented after a
suicide attempt at an emergency department, found that
35% met the criteria for an alcohol use disorder and 27%
met criteria for an SUD at the time of the attempt.
Moreover, the study found that a diagnosis of alcohol
abuse increased the risk of a repeat suicide attempt
threefold, while a diagnosis of illicit drug abuse increased
the risk of a repeat suicide attempt fourfold in the sub-
sequent 12 months. Spirito et al. [106] reported that 12%
of adolescent suicide attempters (12–18 years old) who
presented at an emergency department met the criteria for
an alcohol use disorder (6% alcohol abuse and 6% alco-
hol dependence) and 18% met the criteria for cannabis
use disorder (8.4% cannabis abuse and 9.6% cannabis
dependence).
Eur Arch Psychiatry Clin Neurosci (2012) 262:469–485 479
123
Waldrop et al. [111] found that the weighted population
prevalence of suicidal ideation and attempts was 23.3 and
3.1%, respectively. The Mexican Adolescent Mental
Health Survey found associations between suicidal
attempts and drug use/abuse (OR =1.1 and 3.8, respec-
tively), and alcohol use and abuse (OR =2.4 and 5.4,
respectively) [67]. Furthermore, in this cohort, the onset of
substance exposure and attempting suicide occurred in the
same year in 42% for the use of drugs and in 14% for the
use of alcohol.
Suicide, substance abuse and other psychiatric
disorders: comorbidity matters
Co-occurring substance use and other psychiatric problems
are a prominent characteristic of those seeking help at
mental health services [13,15,44,80,91]. In a clinical
population of adolescents from substance abuse treatment
settings, Diamond and colleagues [27] found that 72% of
adolescent marijuana users had two or more psychiatric
disorders when entering treatment. In a case–control study
of adolescents with alcohol dependence, compared with
adolescents residing in the community without alcohol
dependence, Clark et al. [20] found that the most common
types of psychopathology observed in alcohol-dependent
adolescents included conduct disorder, ADHD, major
depressive disorder and PTSD.
Comorbidity increases the risk of suicidal behaviour and
the severity of the psychiatric illness, especially mood
disorders [8,9,11,52,56] and disruptive behaviour dis-
orders [38,62].
Harrington et al. [40] found that depression in childhood
was a strong predictor of a suicide attempt in early adult
life. The risk is increased when depression is associated
with drug abuse, cognitive distortions, hopelessness and
low self-esteem, a passive coping style, social maladjust-
ment, interpersonal problems and familial and environ-
mental stresses [6].
Goldstein et al. [36] who studied 249 adolescents (aged
12–17 years) with bipolar disorders (BD) in a long-term
naturalistic study found that the lifetime prevalence of
SUD was 16% in these adolescents and that cannabis use
disorder was the most common form of SUD, followed by
alcohol use disorder. They also found that conduct disorder
was significantly associated with SUD and may be con-
sidered a predictor of SUD among adolescents with BD.
Moreover, they reported that SUD was associated with an
increased risk for suicidal behaviour and troubles with the
police (similar to results with adults with BD). In adoles-
cent females with BD, SUD was associated with an
increased rate of pregnancy and abortion.
Discussion
The high incidence of completed and attempted suicide in
substance abusers, as well as the elevated comorbidity
between suicide, substance abuse and psychiatric condi-
tions among adolescents, forces clinicians to deal with a
difficult task. Given the association between substance
abuse and suicidality, the next question is why are these
two behaviours associated.
Substance abuse is a well-known risk factor for attempt-
ing suicide, but some authors raise the question of whether it
is a proximal or a distal risk factor. Hufford [46] suggested
that the acute effects of intoxication may represent a proxi-
mal risk factor for suicidal behaviour. There is evidence that
excessive alcohol use heightens psychological distress,
aggressiveness and suicide-specific alcohol expectancies
and inhibits adaptive coping strategies. This additional bur-
den may be sufficient to move suicidal thoughts into action.
Support for this theory comes from research suggesting that
adolescents who make fatal and non-fatal suicide attempts
exhibit elevated rates of alcohol use and intoxication at the
time of the attempt [43,55,61,95].
However, substance use may also function as a more
distal risk factor for suicidal behaviour [46]. Hufford [46]
suggested that SUD may be associated with increased
stress and co-occurring psychopathology, which in turn
increases the risk of suicidal behaviour [105]. Some studies
reported that substance use among adolescents is positively
related to heightened levels of stress across many areas of
life. For example, it has been associated with poor aca-
demic performance, legal and disciplinary problems and
interpersonal conflicts among adolescents [56,71]. There-
fore, some adolescents who attempt suicide may be moti-
vated by a desire to escape from unbearable stressors,
difficulties or aversive self-awareness such as the realiza-
tion of inadequacies and unmet expectations [37].
Bukstein et al. [14] investigated the risk factors for
suicide in 23 adolescent suicides compared to 12 commu-
nity controls with a lifetime history of substance abuse.
They found that suicides were more likely to be active
substance abusers and to have comorbid major depression,
suicidal ideation within the past week, a family history of
depression and substance abuse, legal problems and the
presence of lethal weapons in the home than controls.
Following Bukstein et al. [14], three main hypotheses can
be postulated to explain the escalation process in substance
use and suicide:
1. Substance abuse ?breakdown in personal relation-
ships ?increased suicide risk;
2. Substance abuse ?change in mood ?suicidal idea-
tion or depression ?suicide attempt;
480 Eur Arch Psychiatry Clin Neurosci (2012) 262:469–485
123
3. Substance abuse ?intoxicating effects ?impaired
judgement ?increased suicide risk.
The presence of a mood disorder (depression or hypo-
mania) may also determine the onset of a secondary sub-
stance use. Following the hypothesis of ‘self-medication’,
some authors have suggested that suicidal behaviour could
also be a reflection of an underlying mood disorder [46].
Some vulnerable individuals with painful affective states
due to psychiatric conditions or having some affective
temperaments traits [82] seem to be predisposed to addic-
tion. The ‘self-medication’ properties of some substances
may reduce stress [57] or increase the drive to use drugs
[54,90,98]. A mechanism of ‘relief/escape’ may be fre-
quently associated with both the choice of suicidal and
substance use behaviours.
Moeller et al. [68] described poor impulse control as a
core behavioural feature of SUD and reported impulsivity
as a behavioural characteristic of suicidal subjects [28,45,
60]. In one study, even after controlling for hopelessness,
neuroticism, external locus of control and extroversion,
poor impulse control remained significantly associated
with adolescent suicidal behaviour [3]. Several authors
have shown that poor impulse control may predict suicidal
behaviour [1,28,45,60,85].
In adolescents and young adults, traumatic events (a
poor family environment and interpersonal and intraper-
sonal events), which have been shown to contribute to
suicide risk [41], are frequent. Stressful life events are risk
factors both for suicidal behaviour and for the onset/esca-
lation of substance use [72,108,113]. Negative conse-
quences often result from a combination of poor impulse
control, stressful life events, suicidal behaviour and sub-
stance use [12,23,87].
Both acute effects (judgment impairment, reduced
inhibitions and worse impulse control) [58] and long-term
effects (neurocognitive dysfunctions and reduced behav-
ioural control) may increase the risk for suicidal behav-
iour [12,99,102,110]. Adolescent substance users often
experience behavioural, affective and cognitive changes,
resulting in dysregulation of aggression, sensation seeking
and impulsivity [19,64,65]. Finally, altered serotonergic
functioning has also been found in suicides and suicide
attempts [59,60,105]. Alterations in serotonergic func-
tioning have also been found to be associated with the
abuse of some substances [70]. Initial abnormalities in
serotonin regulation, together with cell signalling and
signal modulation related to the differential expression of
the serotonin transporter and low levels of brain seroto-
nin, may increase with an increase of substance use [98].
Volkow [109] has suggested that physiological changes
such as serotonergic abnormalities secondary to substance
abuse may gradually worsen mood, increasing the
likelihood of suicidal behaviours, particularly in vulnera-
ble populations.
Dawes et al. [25] proposed a developmental-transac-
tional model integrating a stress-diathesis model [58]
including precursors, prominent risk factors and also pos-
sible mechanisms involved in suicidal behaviour. They
suggested that precursors such as familial factors lead to
neuroticism, hopelessness, mood symptoms and then to
depression while other precursors produce altered serotonin
function and deficits in executive functioning resulting in
impulsive-aggressive traits. Three possible causal path-
ways underlying the vulnerabilities leading to adolescent
suicidal behaviours and having bidirectional interactions
were reported: (1) stressful life events $genetic markers
of serotonin dysregulation $suicide attempts, (2) sub-
stance use $impulsivity and (3) substance use $suicide
attempts.
Mood disorders interacting with stressful life events
may lead in adolescents first to suicidal ideation and then to
suicide attempts. Recent findings in adolescents and young
adults have demonstrated that functional serotonin trans-
porter polymorphisms interacting with stressful life events
may predict depression, suicidality [16] and substance
abuse [21,51,74]. As Bridge [12] suggested, the presence
of other risk factors, such as current drug intoxication,
exposure to suicide or availability of a lethal agent, may
increase the risk of suicidal behaviour.
Finally, another hypothesis such as a desire to escape
problems or the above-mentioned desire for ‘self-medica-
tion’ [46,53] may be proposed to explain the co-occur-
rence of suicidal and substance use behaviours.
That in young substance users, often aggravated by
stigmatizing attitudes [79], contributes to the excess of
mortality in adolescence.
In the meantime, a proper assessment based on the
evaluation of the most relevant specific risk factors and
aimed at identifying those individuals considered to be at
risk is crucial. Several risk factors for suicide must be
assessed. The frequency of drug use, as well as environ-
mental stressors, should be carefully considered by clini-
cians when approaching patients with comorbid SUD and
suicidal risk because they can significantly impact an
adolescent’s emotional well-being. The burden of the
comorbid psychopathology should not be ignored. The
presence of multiple coexisting disorders can be considered
to be a strong predictor of poor outcome in substance users,
increasing both the risk of suicidal behaviour and the
severity of substance abuse.
An investigation of access to lethal weapons, especially
firearms, in the home is necessary. A recent paper [49]
reported that four-fifths of adolescent suicides took place in
the decedents’ homes, and most of the firearms were owned
Eur Arch Psychiatry Clin Neurosci (2012) 262:469–485 481
123
by parents, highlighting the importance of limiting youth
access to firearms. Overall, the presence of available fire-
arms is a relevant factor in establishing the risk of suicidal
behaviour.
Sometimes, in acute cases, hospitalization may be
required; in this case, treatment should be individualized to
address the myriad of potential diagnoses [92]. There is
frequently a need for multi-modal treatment including
group, family, individual and milieu therapy, as well as
crisis-oriented interventions.
The CDC’s National Centre for Injury Prevention and
Control has published a programme with guidelines for
intervention strategies for communities that are interested
in developing prevention programmes for adolescents [73].
The strategies for suicide prevention for adolescents con-
centrate on two general themes: strategies to identify sub-
jects at risk so as to direct them to healthcare centres and
strategies to increase their social support network and their
management of stress.
Patients often avoid bringing up their suicidal thoughts
and plans, but they are more willing to discuss these if the
clinician asks specific questions about any intention to
commit suicide [83,84]. Educating general practitioners
[96], nurses [81] and paediatricians [104] about suicide,
depression and substance abuse can have a major impact on
how patients at risk are evaluated and managed [66]. In a
qualitative study, Bergmans et al. [4] interviewed 25
repeated substance-using suicidal patients about suicidali-
ty, substance use and service use, and also 27 emergency
department staff about their attitudes when providing care
to these men. There was frequently a negative interaction
between the two groups due to feelings of frustration
experienced by the emergency department staff. Moreover,
suicidal patients seemed not to be able to express their
needs and feelings during crises. This can be ameliorated
by the inclusion of social workers as part of the emergency
department team when working with suicidal patients.
One of the most effective strategies for suicide pre-
vention is to teach people how to recognize and respond to
the signals of suicidal tendencies since this increases the
likelihood of at-risk youths seeking help. Everyone can be
a source of encouragement, strength and optimism, teach-
ing and practising problem-solving methods with the
affected person and inculcating a sense of optimism [115].
Treatment compliance is another critical problem,
although only few studies have focused on the long-term
consequences of treatment non-adherence. Groholt and
Ekberg [39] conducted a 9-year follow-up study in a
population of 71 adolescents who had attempted suicide.
They found that 44% of the adolescents made another
suicide attempt; the majority of them received psychiatric
treatment but about half of them attended fewer than three
sessions.
This review should be considered in the light of the
following limitations. First, meta-analytic techniques were
not used to evaluate the results of the research. Second, the
authors chose to report those studies that could support a
broad analysis of the topic. Despite the careful and sys-
tematic search, a number of additional papers may have
been missed. The heterogeneity of the studies presented a
challenge for quality assessment. However, studies inclu-
ded in this review were assessed for quality allowing us to
ascertain the relative contribution of each study to the
systematic review.
The majority of the studies raised many questions
without giving definitive answers. Bias may be introduced
by the inclusion of cross-sectional studies of highly
selected clinical samples. Prospective studies of samples
from clinical settings would permit the investigation of the
timing, duration, and severity of predictors of suicidal
behaviour in populations of substance abusers [114].
The relationship between suicide and drug use in ado-
lescents over time is not necessarily linear, and rates of
adolescent substance abuse have fluctuated in recent dec-
ades [49]. Similarly, the drugs abused vary over time.
Finally, research on adolescent suicide and substance abuse
has been confounded by changes in diagnostic criteria, lack
of age-specific criteria to diagnose adolescent SUD,
changes and advances in the treatment of adolescent sub-
stance abuse and a failure to investigate the presence of
substance use in the earlier studies of adolescent suicidal
behaviour [92].
Conclusions
In summary, the present review confirmed the frequent
association between substance use/abuse and adolescent
suicidal behaviour. Remedying the actual deficits of the
research about the association between suicidal behaviour
and SUD as well as exploring possibilities for making
suicide prevention more effective in clinically at-risk
groups are key issues for the future. Future longitudinal
studies, including samples from epidemiologically repre-
sentative populations as well as clinical samples, are
required to better understand how targeted resources can be
selectively oriented to particular at-risk groups.
Conflict of interest None.
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... Childhood trauma, including physical, emotional, and sexual abuse and physical neglect, is noted to be a modifiable risk factor for suicide [24]. Problematic substance use added a further complication, echoing research findings of the strong relationship between suicide and substance abuse [25]. The resolution, a final act taken by each of the men, was foreshadowed at the start. ...
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... The data also did not allow for mediation and moderation analyses. Given the increased risk for suicide among those with posttraumatic stress disorder (Krysinska & Lester, 2010), substance use issues (Pompili et al., 2012) and family distress or isolation (Frey & Cerel, 2015), it is likely that youth who have experienced childhood trauma have additional factors that increase their risk for sex trafficking. Future research needs to examine the role of additional risk factors in understanding the relationship between ACEs and sex trafficking more clearly. ...
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Background: Exposure to firearm victimization has often been overlooked as a sequela of substance use disorders (SUD). Objectives: The overall objective of this study was to explore firearm-related victimization and associated factors among men and women entering a supportive housing SUD recovery program. Methods: This study used program intake information from men (n = 1,758) and women (n = 1,066) clients entering a SUD recovery program. Results: Results found that almost half (49.3%) of the clients entering the program had ever been threatened with a firearm or held at gunpoint, and one-quarter of those clients had experienced firearm-related threats in the 6 months before entering the program. Economic vulnerability, mental health problems, polysubstance use, interpersonal victimization, and early use of drugs and alcohol were associated with firearm-related threat exposure. Many of the factors associated with firearm-related threat exposure were similar for men and women. Multivariate results found that polysubstance use (OR 1.16 men and 1.13 women), number of adverse childhood events (OR 1.13 men and 1.09 women), and interpersonal victimization (OR 3.41 men and 2.05 women) in the 6 months before program entry were significantly associated with ever being threatened with a firearm. Suicidality (OR 1.53 men and 1.80 women) and interpersonal victimization (OR 6.38 men and 6.08 women) were associated with being threatened with a firearm in the 6 months before program entry for both men and women. Conclusion: Results suggest there is a need for firearm-related risk reduction interventions for individuals in SUD recovery programs.
• Substance use has been identified as a significant risk factor in nonfatal and fatal suicides during adolescence. A • prehensive questionnaire on patterns of alcohol and other drug use, early childhood and nuclear family psychological and behavioral history, and previous suicidal attempts was completed by 298 (88%) of 340 outpatient adolescent substance abusers in three geographic regions east of the Mississippi River. An abbreviated Beck Depression Inventory was included to ascertain current symptoms of depressed mood. Adolescents admitting to a previous suicide attempt (30%) were compared with two age- and sex-matched samples. Substance abusers were three times as likely as a normative population of non—drug-using ageand sex-matched peers to make a suicide attempt. Thirty-three percent of attempts reported occurred prior to high school. Both the wish to hurt oneself and actual suicide attempts were found to increase significantly after the initiation of substance use. Forty percent used drugs within 8 hours before the suicide attempt, and 23% of attempters reported that their families continued to have a firearm with ammunition in the home following the suicide attempt. Adolescent substance abusers who had attempted suicide were significantly more likely than a matched group of nonattempters in the same drug treatment facility to: (1) complain of usually feeling "blue" or sad (depressed affect) during early childhood, (2) identify important childhood behavioral problems, (3) identify long-standing self-perceived impaired self-concept, and (4) identify serious parental problems, such as chronic depression or alcoholism. Self-perceived chronic loneliness in childhood appears to be a singularly important initiator of adolescent drug use and subsequent suicide attempts among drug abusers.(AJDC. 1990;144:310-314)
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• The characteristics of adolescent suicide victims (n = 27) were compared with those of a group at high risk for suicide, suicidal psychiatric inpatients (n = 56) who had either seriously considered (n = 18) or actually attempted (n = 38) suicide. The suicide victims and suicidal inpatients showed similarly high rates of affective disorder and family histories of affective disorder, antisocial disorder, and suicide, suggesting that among adolescents there is a continuum of suicidality from ideation to completion. However, four putative risk factors were more prevalent among the suicide victims: (1) diagnosis of bipolar disorder; (2) affective disorder with comorbidity; (3) lack of previous mental health treatment; and (4) availability of firearms in the homes, which taken together accurately classified 81.9% of cases. In addition, suicide completers showed higher suicidal intent than did suicide attempters. These findings suggest a profile of psychiatric patients at high risk for suicide, and the proper identification and treatment of such patients may prevent suicide in highrisk clinical populations.
Article
• The prevalence of mental disorders (DSM-III-R Axes I and II) among adolescent suicide victims (n = 53) was investigated in a nationwide psychological autopsy study in Finland. The data were collected comprehensively through interviews of the victims' relatives and attending health care personnel and from official records. Following independent assessment by two psychiatrists, the DSM-III-R diagnoses were assigned in consensus meetings. A large majority of the victims (94%) suffered from a mental disorder. The most prevalent disorders were depressive disorders (51%) and alcohol abuse or dependence (26%). The prevalence of adjustment disorders (21%) was higher than in most studies from other countries. Personality disorder was diagnosed in 32% of the cases. Comorbidity was found in 51% of the victims. The results indicate a strong relatedness between adolescent suicide and the presence of depression, antisocial behavior, and alcohol abuse.
Article
• A survey evaluated the lifetime and current prevalence of mental disorders in 501 patients seeking assistance with alcohol and other drug problems at an addiction research and treatment facility. Information was gathered using the National Institute of Mental Health Diagnostic Interview Schedule (DIS) and computer diagnoses were generated according to DSM-III criteria. Four fifths (78%) of the sample had a DIS lifetime psychiatric disorder in addition to substance use, and two thirds (65%) had a current DIS mental disorder. Excluding the unreliably diagnosed generalized anxiety disorder, the most common lifetime disorders were antisocial personality disorder, phobias, psychosexual dysfunctions, major depression, and dysthymia. Patients who abused both alcohol and other drugs were the most psychiatrically impaired. Patients with DIS psychiatric disorders had more severe alcohol and other drug problems. Barbiturate/sedative/hypnotic, amphetamine, and alcohol abusers were the most likely to have a DIS mental disorder.