Alcohol Abuse/Use in Suicide Attempters: A Study in Psychiatric Out-Patient Clinic of a Teaching Hospital of Eastern Nepal

Abstract

Background:
Alcohol use is common in Nepalese society. Substance use/abuse is described as one of the 3 of the deadliest combination for suicide. There is a scant data from Nepal about the relationship of alcohol with suicide. We aim to see alcohol use/ abuse in cases of suicide attempt.
Methods:
It is a hospital based descriptive study conducted among the cases with suicide attempt. All the patients consulting the investigating psychiatrist of a department of psychiatry of a teaching hospital in eastern Nepal within study period were enrolled after informed consent. With usual detailed work-up, suicidal state was ascertained. Relevant informations were recorded in the proforma. An intensive exploration was made in all suicide-attempt subjects into a range of alcohol use/
abuse. Alcohol use/disorder was operationally sorted out into various categories in relation to suicide attempt.
Results:
Out of 150 total cases of suicide attempt, 68% (102) were married and 58.7% (88) were female. Average age was 28.8 ± 12.329 years. More of the cases were from village and semi-urban settings. Some cases had used alcohol for the first time immediately prior to the attempt and some other had Alcohol dependence syndrome (ADS). A clear and possible association was seen in 56/150 (37%).
Conclusion:
Alcohol use/abuse is common and appears to precipitate and predispose the DSH attempt.
Keywords:
Alcohol use; Deliberate self harm; Alcohol use disorder; Nepal; Suicide

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Abbreviations: ADS, alcohol dependence syndrome; ARD,
alcohol related disorder; AUA, acute use of alcohol; AUD, alcohol
use disorders; BPKIHS, bp koirala institute of health sciences; DSH,
deliberate self harm; DSM, diagnostic and statistical manual of men-
tal disorders; HUA, harmful use of alcohol; ICD 10, the international
classications of diseases 10th edition; IERB, institute ethical review
board; SPSS, statistical package for social studies
Introduction
Suicide is a complex phenomenon with multi-factorial causation.1–4
Complex interplay of various psychological, social, cultural and
biological factors is implicated behind suicide and its attempt2–5 though
many of times; some particular precipitating event/factor stands out in
particular set-up and region indicating need for the identication and
some specic strategies.3 Among suicide attempters, the combination
of depression, hopelessness and substance/alcohol use/abuse has been
reported as the deadliest one as risk.5 Alcohol use/abuse is common
and suicide/attempt has been observed more among alcohol users in
Nepalese context too.6,7 Data on magnitude of alcohol use/abuse in
suicide/attempt will help guide devising needful strategies.3 There
is, however a dearth of information about alcohol use and related
disorders among suicide attempters in Nepalese setting. This study
was conducted in the department of psychiatry, B.P. Koirala Institute
of Health Sciences, Nepal in 2011 to sort out the alcohol use/ related
disorders among suicide attempters.
Methods
It is a hospital based-cross sectional descriptive study looking into
alcohol use/abuse among suicide attempters. All patients consulting
the investigating psychiatrists-team of B. P. Koirala Institute of
Health Sciences, Dharan, Nepal, within study period (12 months,
2010 October/ 2011 September) were enrolled after informed consent.
With usual detailed work-up, suicidal state was ascertained. Relevant
information’s were recorded in a predesigned proforma. An intensive
exploration was made in all the subjects into a range of alcohol use and
alcohol use disorders (ICD-10).8 Alcohol use/abuse was categorized
in relation to suicide attempt into:
a. Single and rst time use just prior to the attempt.
b. Occasional but not during attempt.
c. Occasional and also during attempt.
d. Harmful use and also during attempt.
e. Harmful use but not during the attempt.
f. Regular use/Alcohol dependence syndrome (ADS) but not
during attempt.
g. ADS and use during attempt. The information and views col-
lected from the subjects and their care takers (when the sub-
ject was not in position to respond) (through semi-qualitative
approach) regarding the role of alcohol use and disorder in
the suicide attempt were sorted out. The information was kept
condential. Ethical clearance was obtained from the Institute
Ethical Review Board of BPKIHS. Data were entered into a
computer and analyzed using ‘Statistical Package for Social
Studies’ (SPSS) - software 17.
MOJ Addict Med Ther. 2018;5(1):25‒29 25
© 2018 Shakya. This is an open access article distributed under the terms of the Creative Commons Attribution License, which
permits unrestricted use, distribution, and build upon your work non-commercially.
Alcohol use/abuse in suicide attempters: a study in
psychiatric out-patient clinic of a teaching hospital of
eastern Nepal
Volume 5 Issue 1 - 2018
Shakya DR
Department of Psychiatry, BP Koirala Institute of Health
Sciences, Nepal
Correspondence: Dhana Ratna Shakya, Professor, Department
of Psychiatry, BP Koirala Institute of Health Sciences, Dharan,
Ghopa-18, Sunsari, Koshi, Nepal, Tel 977-025-525555, Ext 3225,
5334, Email drdhanashakya@yahoo.com
Received: January 28, 2018 | Published: February 07, 2018
Abstract
Background: Alcohol use is common in Nepalese society. Substance use/abuse is
described as one of the 3 of the deadliest combination for suicide. There is a scant data
from Nepal about the relationship of alcohol with suicide. We aim to see alcohol use/
abuse in cases of suicide attempt.
Methods: It is a hospital based descriptive study conducted among the cases with
suicide attempt. All the patients consulting the investigating psychiatrist of a
department of psychiatry of a teaching hospital in eastern Nepal within study period
were enrolled after informed consent. With usual detailed work-up, suicidal state
was ascertained. Relevant informations were recorded in the proforma. An intensive
exploration was made in all suicide-attempt subjects into a range of alcohol use/abuse.
Alcohol use/disorder was operationally sorted out into various categories in relation
to suicide attempt.
Results: Out of 150 total cases of suicide attempt, 68% (102) were married and
58.7% (88) were female. Average age was 28.8 ±12.329 years. More of the cases were
from village and semi-urban settings. Some cases had used alcohol for the first time
immediately prior to the attempt and some other had Alcohol dependence syndrome
(ADS). A clear and possible association was seen in 56/150 (37%).
Conclusion: Alcohol use/abuse is common and appears to precipitate and predispose
the DSH attempt.
Keywords: alcohol use, deliberate self harm, alcohol use disorder, Nepal, suicide
MOJ Addiction Medicine & erapy
Research Article Open Access

Alcohol use/abuse in suicide attempters: a study in psychiatric out-patient clinic of a teaching hospital
of eastern Nepal 26
Copyright:
©2018 Shakya
Citation: 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(1):25‒29. DOI: 10.15406/mojamt.2018.05.00086
Results
a. Out of the total of 150 cases enrolled in this study; 88 were
female, with M : F ratio of 0.71: 1.
b. Average age was 28.8 ±12.329 years, with age range of 14-
81. Patients of age groups (20-29) and (<20) years constituted
the largest proportion 40.7% and 22.7%. Majority 102, 68.0%
were married; with 43, 28.7% single, 3, 2.0% widow and 1,
0.7% each divorcee and engaged. Great majority 82% were
educated to various levels (Table 1).
c. Caste/ethnicities classied as per the system of ‘Government
of Nepal, 2007 for Free Health services, District Health Ser-
vice Report 2064’ revealed: Upper Hill caste (e.g. Brahmin,
Chhetri, Thakuri, etc.), disadvantaged Hill Janajati (e.g. Ma-
gar, Rai, Tamang, Limbu, Sherpa, etc) and relatively advan-
taged Janajati (e.g. Newar, Gurung, Thakali) as the commo-
nest caste/ethnicities. Hindu cases (127, 84.7%) predominated
here; with 11, 7.3% Kirat; 6, 4.0% Buddhist; 4, 2.7% Muslim
and 2, 1.3% Christian. Half of the total 75, 50.0% were from
villages; 24, 16.0% from cities and 51, 34.0% semi-urban (Ta-
ble 2).
d. Majority of these subjects (115, 76.7%) had psychiatric disor-
der. The most common psychiatric diagnosis was depression
(unipolar mainly and some bipolar) (Table 3).
e. Consumption of poison was the most common mode (118,
75%) of suicide attempt*. Among the 118 subjects attempting
suicide by consuming poison, the commonest poison used was
Organophosphorous compounds. Two subjects had consumed
2 poisons (Table 4).
f. Many cases 71/150 had high intent and 58/150 had high le-
thality of effect of the attempt (Table 5).
g. More than half of subjects (82/150, 54.7%) reported to use
psychoactive substance, mainly alcohol (Table 6).
h. One third of the subjects 50/150, 33.3% reported to consume
alcohol immediately prior to the suicide attempt (Table 7).
i. In 56, 37.3% cases, some relationship (denite and possible)
was reported between alcohol use/abuse and suicide attempt
(Figure 1).
Table 1 Age, Marital status and Education of suicide attempt cases
Age group (yrs.) No. (%)
<20 34 (22.7)
20 - 29 61 (40.7)
30 - 39 26 (17.3)
40 - 49 18 (12.0)
≥05 11 (7.3)
Marital status
Single 43 (28.7)
Married 102 (68.0)
Separate/ divorce 1 (0.7)
Widow 3 (2.0)
Engaged 1 (0.7)
Education level
Illiterate 27 (18.0)
Age group (yrs.) No. (%)
Literate - 3 16 (10.7)
4 - 7 29 (19.3)
8 - SLC 52 (34.7)
PCL and above 26 (17.3)
Table 2 Caste/Ethnicity, Religion, Family type and Residential settings
Caste/ Ethnic groups No. (%)
Upper Hill 40 (26.7)
Upper Terai 15 (10.0)
Relatively Advantaged Janajati 16 (10.7)
Religiously Minorities/ Muslim 5 (3.3)
Disadvantaged Non-Dalit Terai 21 (14.0)
Disadvantaged Hill Janajati 39 (26.0)
Disadvantaged Terai Janajati 1 (0.7)
Hill Dalit 11 (7.3)
Terai Dalit 2 (1.3)
Religion
Hindu 127 (84.7)
Buddhist 6 (4.0)
Muslim 4 (2.7)
Christian 2 (1.3)
Kirat 11 (7.3)
Family Type
Nuclear 74 (49.3)
Joint 54 (36.0)
Broken/ Separated/ Alone/ Other 22 (14.7)
Residential Setting
Urban 24 (16.0)
Semi-Urban 51 (34.0)
Rural 75 (50.0)
Table 3 Psychiatric diagnoses*
ICD Code Psychiatric Diagnosis No. (%)
Suicide, Impulsive 35 (23.3)
Present 115 (76.7)
Physical Disease 8 (5.33)
F10-19 Psychoactive Substance Use 48 (32.00)
F20-29 Schizophrenia, Schizotypal &
Delusional 10 (6.67)
F30-39 Mood (Affective) 59 (39.33)
F30-34,38,39 Manic Episode, Bipolar Affective 1 (0.67)
Depressive Episode, Bipolar
Affective 4 (2.67)
Depressive (Including Dysthymia-
1) 54 (36.00)
Stress Related/Adjustment 17 (11.33)
Others Organic/ Mental Retardation/
Personality 16 (10.67)
*Multiple response category - One respondent may have one or more
responses.
Table Continued...

Alcohol use/abuse in suicide attempters: a study in psychiatric out-patient clinic of a teaching hospital
of eastern Nepal 27
Copyright:
©2018 Shakya.
Citation: 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(1):25‒29. DOI: 10.15406/mojamt.2018.05.00086
Table 4 Mode of Suicide attempt and Type of Poisons used*
Mode of
attempt No. (%) Mode of poisoning No. (%)
Poisoning 118 (74.55) Organophosphorous 92 (77.9)
Hanging 23 (15.33) Zinc Phosphide 15 (12.7)
Strangulation 5 (3.33) Drug Overdose 6 (5.1)
Cut/Injury 6 (4.00) Chemical 4 (3.4)
Other/Mixed 9 (6.00) Other/Mixed 3 (2.5)
Table 5 Intent and Lethality of suicide attempt
Intent of attempt No. (%) Lethality of attempt No. (%)
Low 26 (17.3) Low 38 (25.3)
Moderate 44 (29.3) Moderate 54 (36.0)
High 71 (47.3) High 58 (38.7)
Not available 9 (6.0) Not applicable 0 (0)
Table 6 Substance use among out patients with Suicide attempt*
Substance use No. (%)
None/Never 68 (45.3)
Occasional/Social Alcohol 20 (13.3)
Harmful Use of Alcohol 27 (18.0)
Alcohol Dependence 20 (13.3)
Alcohol + Other Substance 8 (5.3)
Other Substance 8 (5.3)
Inadequate 7 (4.7)
Table 7 Alcohol use during Suicide attempt
Substance use during suicide attempt No. (%)
Not Present 91 (60.7)
Never Used 68 (45.3)
Occasional but not During Act 13 (8.7)
Harmful Use but not During Act 9 (6.0)
Present 50 (33.3)
First time Use at the Time of Act 5 (3.3)
Occasional and Use During Act 7 (4.7)
Harmful and use During Act (Excluding First Time Use) 18 (12.0)
Regular and Use During Act 8 (5.3)
Increased Regular Use During Act 12 (8.0)
Inadequate Information 9 (6.0)
Discussion
Suicide and its attempts is a serious problem with great impact
for individual, family, society and nation.9,10 Its rate is reported to
increase in recent years,2 more so in the developing countries.10 Nepal
is also witnessing high and rising suicide rates, in various settings11,12
though we have a limited nationwide community based data.13
Suicide is the result of a complex process of interaction of protective
and risk factors, i.e. interplay of bio-psycho-socio-cultural factors.1–5
Hence, the prevention efforts are challenging and also required to
be multi-factorial and multi-dimensional.2,9 As with other health
problems, suicide prevention endeavours include primary, secondary
and tertiary prevention in the form of universal, selective, targeted
and indicated interventions.2,9 Related factors may predispose or
precipitate the suicide phenomena and may also contribute to cause
repeated attempts.2,9 Important perspective is to analyze and address
modiable factors in a particular setting and locality.3,14 Identication
of modiable factors and managing them consist of an important
aspect of suicide prevention.3 We have some studies looking
into associated clinical correlates including depression and other
psychiatric morbidities15 and common stressors16 in suicide attempt
subjects. We aim in this study to see the alcohol use and disorders
among suicide attempt cases coming in psychiatric department of a
teaching hospital in eastern Nepal. Since alcohol use and disorders are
remarkably high in this part,7,17 we view that this effort would make
a meaningful step towards comprehensive understanding and suicide
prevention here.
Occurrence of any factor in a health problem can be of coincidental,
co-occurrence or causal (cause and effect) relationship. Alcohol
use and its related disorders in suicide also may be one of these
possibilities; complex and still far from conclusive.2,3,9,14 In this study,
we aim to see the occurrence of a spectrum of alcohol use and alcohol
use disorders among the psychiatric patients seeking consultation for
suicide attempts. Alcohol use/abuse was operationally categorized in
this study in relation to suicide attempt into:
a. Single and rst time use immediately prior to the attempt.
b. Occasional but not during attempt.
c. Occasional and also during attempt.
d. Harmful use and also during attempt (excluding rst time use
just prior to the attempt in this study which is conceptually a
Harmful use).
e. Harmful use but not during the attempt.
f. Regular use/Alcohol dependence syndrome (ADS) but not
during attempt.
g. ADS and use during attempt. We explored in the subjects (by
semi-qualitative approach; i.e. their information and view)
into the possibility of the role of the alcohol use and related
factors in suicide attempt. Analysing (statistical and deni-
te) the relationship and mechanisms of alcohol and suicide
is beyond the scope of this study; however, this could be the
area of further study in this setting as well.
Other perspective is acute alcohol use (AUA) just prior to the
attempt and chronic long standing use resulting into alcohol use
disorder (AUD) among the cases of suicide attempt. Both of these
have been reported higher among suicide and suicide attempts.3 We
have 50/150 (33.3%) of the suicide attempt subjects using alcohol
before the attempt which is comparable to available literature.3,18,19
Nearly one third of the subjects (32%) fullled the criteria for one
or other alcohol use disorder (ICD-10: Acute Intoxication, Harmful
use, Alcohol dependence syndrome, other induced disorders)8 again
keeping this study in line with available data from other parts.3,20
Exploration was made through semi-qualitative approach into
the relationship/association of alcohol in suicide attempt. Some

Alcohol use/abuse in suicide attempters: a study in psychiatric out-patient clinic of a teaching hospital
of eastern Nepal 28
Copyright:
©2018 Shakya
Citation: 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(1):25‒29. DOI: 10.15406/mojamt.2018.05.00086
association was seen in 56/150 (37%) of the deliberate self harm
(DSH) attempters. Five cases had used alcohol for the rst time prior
to the attempt and some other had Harmful use (18%), and Alcohol
dependence syndrome (ADS) (13.3%) comparable to large scale
study from Canada.9 We have over all 50% of suicide attempt cases
who have alcohol use/abuse, replicating the similar nding in other
areas.1,9 It makes a strong ground for the alcohol prevention programs
here as well which will positively impact the public mental health and
help reduce suicide risk in/directly.2
Both suicide/attempt and substance are stigma laden issues and
their information is hidden.9 We made an attempt to collect information
about suicide and alcohol use/abuse in suicide attempt cases. Hence,
the collected information is liable to forgetting, modication and
hiding. In some cases, information was not available/inadequate in
this study to ascertain some important issues, i.e. intent/ lethality of
suicide attempt, substance/alcohol use/disorders in these suicide cases.
Many of these cases might add to the gure of substance/alcohol use/
abuse in these cases during the suicide and as a whole. Second issue
is that our study is hospital based and is among psychiatry patients
seeking consultation for suicide attempts. This bias may limit its
generalization to other setting. However, we believe that for a suicide
like phenomenon (relatively epidemiologically rare, complex and
stigmatized issue), it is a method3 and it does not make difference
for the study objective of looking into alcohol ab/use among suicide
attempters. Denite statistical correlational analysis and other in-
depth cause effect analysis is beyond the scope of this study which
could be the objective of further study though challenging in this
type of subject.2 We intended only to directly see the occurrence of
alcohol use/abuse in suicide attempt cases. We did not mean in this
work to intensively explore in-depth to other possible bio-psycho-
social and cultural factors somehow associated with suicide attempt
in acute alcohol use (AUA), e.g. circumstances/motivation to drink,
distress/mental state, impulsivity, etc. and in alcohol use disorder
(AUD) subjects, e.g. depressive disorder, AUD symptoms severity,
low social support, stressful life events, medical illness or complaints,
and unemployment or other indications of economic adversity etc.
which are not less important.3
This study is however expected to open avenues for the in-depth
and large study on the relationship of substance and suicide and might
indicate various future study areas, e.g. effect of acute (AUA) and
chronic use (AUD), many other associated factors. Overarching the
objective of this study would be to devise the strategies as targeted
and indicated measures for these high risk and survivors of suicide
attempts in this setting, e.g. sensible/reduced drinking, comprehensive
treatment including that for alcohol problem,3 exploring and
monitoring the suicide risk at intervals in follow ups and consultations.2
For this, it is important to give information and training to the related
stakeholders, e.g. general practitioners and other health professionals,
parents, teachers, clean ex-users of substance coming in contact with
at-risk individuals.2
Conclusion
Among the subjects seeking psychiatric consultation for suicide
attempt; female were more, majority were less than 30 years and
more were married. Three fourths had psychiatric disorder, the
most common being depression. Poisoning was the most common
mode of suicide attempt and the commonest poison used was
organophosphorous compound. Half of these subjects reported to use
psychoactive substance, mainly alcohol. One third of the cases had
consumed alcohol immediately prior to suicide attempt. Some (clear
and possible) relationship was seen between alcohol use/abuse and
the suicide attempt in 37% of the cases. This indicates the need to
explore and treat substance/alcohol use disorder simultaneously in
these suicide attempt cases and to screen and manage suicide risk in
alcohol ab/use cases.
Declaration
Ethics approval and consent to participate- Approval from
Institute Ethical Review Board (IERB) of BPKIHS (Ref. No.- Aca
216/068/069) and Consent to participate taken from the subjects.
Consent to publish- Since no individual detail, images, or videos
are involved and condentiality not breached, Not Applicable to this
study. Availability of data and materials since it is conducted among
the clinical subjects in a hospital setting and information needs to be
kept condential for individual subjects (participant condentiality),
kept with investigator team.
Acknowledgements
Prof. Rupa Singh, Department of Paediatrics and Neonatology,
BPKIHS.
Conict of interest
The author declares no conict of interest.
Funding
None.
Authors’ contributions
Overall responsibility born by the author (solo).
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Citation: 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(1):25‒29. DOI: 10.15406/mojamt.2018.05.00086
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